recovery Marty Lerner PhD

Defining the Problem and Finding the Solution

eating disorder

A Guide To

Acknowledgments

No program, set of ideas, or distillation of knowledge is possible

without the collective energy and contributions of many. The

compilation of experiences and concepts incorporated within

this book is certainly no exception. Were it not for the generous

contributions and dedication of the people who have worked

at Milestones, as well as, those who remain here, this program,

book, and continuing legacy would not exist. It truly does take

the proverbial “village” to make it all happen.

I would be remiss if I did not give a special thanks to my family,

especially my wife, Michele. I suspect I could, and perhaps

should, fill the pages of another book about her patience, love,

support, and, did I mention patience, with me. Aside from being

an inspiration and the love of my life, Michele has taught me

more than anyone else about recovery and getting through the

good and bad times together.

Of course my daughters, Janelle and Danielle are not to be

excluded, they constantly teach me about the value of

tolerance, patience, and unconditional love. I suspect our

children are the legacy we leave behind when all is said and

done.

And, there’s Reggie – the official service dog of Milestones.

Without his bouncing around the halls and group room, Milestones

would not be the same. Actually, a unique thank you is due to all

of our dogs – since just about everyone on the Milestones staff has

a canine member of the family. Biscuits for everyone

FORWARD

Over the course of several years, probably more than I’d like to

admit, the professional community has become split as to how to

view, let alone treat, most eating disorders. If we distill the basic

essence of the division, it would come down to those who view an

eating disorder as a mental illness and those who look at these

disorders as an addictive disease. What follows comes from the

latter camp. It is the intention of this book to provide both

anecdotal and empirical evidence to support the notion that most

eating disorders fit the accepted criteria common to an addictive

disease. Doing so has significant implications for successful

treatment.

The first section of this book addresses the addiction thesis. In

doing so, reference is made to the American Psychiatric

Association’s most recent description of addiction, as well as, the

criteria it utilizes to diagnose an addictive disorder. This allows the

reader to decide for her, or himself, whether the proverbial shoe

fits. I’ve also added a few articles to provoke additional thoughts

on the matter. As with most addictions, in the end the “addict”

must be able to make the diagnosis him/herself in order to begin

the process of recovery. Doing otherwise does little more than

provide an intellectual framework to further the symptom of

denial.

The second section begins to explore the commonality of eating

disorders and attempts to debunk the belief eating disorders

represent separate and different disease entities. The common

thread existing among the various flavors of eating disorders is

reviewed and the trap of focusing on weight, appearance, and

dieting is exposed. Setting the stage for treatment thus begins with

defining the problem.

The third section begins to look at the recovery process at

Milestones. By distilling the basic elements of long-term recovery,

participants in the program learn about, and most importantly

practice, a set of skills that virtually guarantees freedom from

addictive relationships with their eating disorder. In doing so, “one

day at a time” the physical, emotional, and spiritual symptoms

inherent with an addiction begin to change course and recovery

follows.

The fourth section focuses on maintaining your recovery and how

S.E.R.F (Spirituality, Exercise, Rest and Food Plan) can assist you.

The fifth section of this book is devoted to continuing care and the

role of support groups such as OA [Overeaters Anonymous],

Anorexics and Bulimics Anonymous [ABA], Alcoholics Anonymous

[AA], Narcotics Anonymous [NA], etc. can help you maintain your

recovery.

The last section addresses insurance concerns with regard to

treatment and the types of questions you should ask any

treatment center before deciding to attend their program. I have

also included several “abstinent” recipes in this final section.

I hope you find this book helpful in your search for recovery.

Marty Lerner, Ph.D. Milestones in Recovery, Inc.

© Marty Lerner, Ph.D. May, 2015

All rights reserved. No part of this publication may be Reproduced without the author’s permission.

Table of Contents

Chapter 1 – The Addiction Thesis for Eating Disorders

Eating Disorders – Addictive or Psychiatric Illness - 1

Table 1.0-Diagnostic Criteria for Substance Dependency APA Guideline - 3

Dopamine – the “Feel Good Brain Chemical “– 8

Dopamine, Brain Chemistry and Anorexia – 11

The Case for Commercial Food Addiction – Bloomberg – 13

Closing Thoughts – Nature of the Beast- 24

Chapter 2 – Common Denominators in Eating Disorders

Defining the Problem – 29

“If it Walks Like a Duck” – 31

Table 2.1 Similarities among Eating Disorders- 35

Co-existing Addictions and Related Problems – 37

Table 4.1 – The Addiction Pyramid – 39

Table 4.2 – Dual Diagnoses Associated with Eating Disorders – 42

Cross Addiction and Co-existing Issues – 43

Body Image and Body Dysmorphic Disorder – 43

Internal/External Cues: What makes us Different?- 47

My Friend Harry- 49

The Restricting Side of the ED Coin – 51

And the Good News – Long-term recovery is possible – 53

What Comes First – It’s the Egg – 54

Chapter 3 – Recovering from an Eating Disorder

The Roadmap – When all Else Fails, Follow the Directions – 57

A Word about Therapy - 58

What Works and What Doesn’t Work - 58

Therapy or Therapeutic Setting- 61

The Secret to Recovery- 64

Living in the Solution: The Hard Work – 66

Principles of Constructive Living- 67

And for the Perfectionist-71

Triggers and the Paula Goldberg Theory- 72

So What, Now What – Move a Muscle, Change a Thought- 77

Table 3.1 “Behavior First – 79

In Other Words – Easy does it, but do It! - 79

Control Issues – 83

The Foundation of Recovery – S.E.R.F. – Page 85

It’s All About the Food – Isn’t it? - 88

To Weigh or Not to Weigh, That is the Question- 90

Measuring Recovery- How am I Doing?-92

Chapter 4: Maintaining your Recovery

SERF Lessons- 95

Spirituality – Give me an “S”- 95

An Exercise in Futility – Give me an “E” – 98

Rest, the Balance between work and play- Give me an “R”- 100

Food Plans: Food for Thought – Give me an “F” – 103

Basic Tenets of a Recovery Food Plan – 106

Healthy Relationships – The 4 A’s – 109

Relationships in Recovery – “Rules of the Road” – 112

Compliance vs Acceptance – 114

The Transition Home – 119

Summary – 120

Chapter 5: Continuing Care after Treatment

12 Step Groups and On-Going Recovery – 124

Open Letter for OA Text – 127

S.M.A.R.T. Recovery – An Alternative or Add on to 12 Step Programs – 132

Continuing Care Resources – 138

Chapter 6: Additional Information

Understanding Insurance for treatment – 141

Abstinent Recipes- 145

Chapter One The Addiction Thesis for Eating Disorders

"What we see depends mainly on what we look for."

- Sir John Lubbock

1

Eating Disorders – Addictive or Psychiatric Illness

The committee of the American Psychiatric Association assigned

the task of defining the criteria for chemical dependency, recently

extended these to include all substance dependencies*. It goes

further to recommend a minimum of three of the seven criteria be

met to justify the diagnosis of dependency. * See Table 1.0 APA

Criteria for Dependency

When we examine an eating disorder from an addictions

perspective, the criteria seems to fit equally well. Although some

would argue that food is not an addictive substance, that debate

goes beyond the scope of this chapter for the moment. The point

is both substances and behaviors are capable of emerging as

addictions. Some of us in the professional community have come

to delineate between substance dependency and addictive

patterns of behavior by coining the term “process addictions” for

the latter. As far as I’m concerned, “a rose is a rose” no matter

what you care to name it.

Perhaps the following quote from the American Society of

Addiction Medicine’s task force on addiction best summarizes the

true nature of addiction, and in effect, an eating disorder.

2

“Addiction is a primary, chronic disease of brain reward,

motivation, memory and related circuitry. Dysfunction in these

circuits leads to characteristic biological, psychological, social and

spiritual manifestations. This is reflected in the individual pursuing

reward and/or relief by substance use and other behaviors. The

addiction is characterized by impairment in behavioral control,

craving, inability to consistently abstain, and diminished

recognition of significant problems with one’s behaviors and

interpersonal relationships. Like other chronic diseases, addiction

involves cycles of relapse and remission. Without treatment or

engagement in recovery activities, addiction is progressive and can

result in disability or premature death.” *American Society of

Addiction Medicine, 2012

To see if “the shoe fits”, you might take the quote above and simply

insert the phrase eating disorders in lieu of the word addiction.

Likewise, the words restricting, purging, binge eating, and so forth

could be inserted. In my professional experience, the shoe fits

quite well. It may be time to look at an eating disorder with respect

to its’ real nature rather than surface appearances. The

implications for treatment and long-term recovery are profound.

Let’s take a moment and review the seven criteria the APA lists as

symptomatic of dependency [aka addiction]. I’ve added a few

comments for each criterion relating it to an eating disorder.

3

Table 1.0

DSM V: Diagnostic Criteria for Substance Use Disorders*

1 – Tolerance (marked increase in tolerance amount; marked

decrease in effect)

Anorexia – need for continued weight loss or restriction of

caloric intake to experience same effect and avoid negative

emotional state. Bulimia and Binge Eating Disorder – need for

increased frequency and amount to achieve the same physical

/ emotional effect.

2 – Characteristic withdrawal symptoms; substance taken to

relieve withdrawal

In many instances, perhaps not as "dramatic" as drug

withdrawal, the phenomenon of craving, as well as symptoms

of irritability, loss of concentration, headaches, and a variety

of other physical symptoms similar to hypoglycemia and

alcohol withdrawal, may be experienced. Depression and

anxiety are common effects of withdrawal from binge eating and

bulimia. Weight restoration is often associated with short-term

anxiety and depressed mood among those suffering with

anorexia.

4

3– Substance taken in larger amounts and for longer periods

than intended

Anorexia - decreased body weight is never enough – continued

pursuit of thinness persists despite achievement of weight

goals.

Bulimia and Binge Eating – “I’ll quit tomorrow” phenomenon or

continuing with binge eating and/or purging much longer than

planned, resulting in missed work or social obligations.

4– Persistent desire or repeated unsuccessful attempts to quit

Bulimia and Binge Eating – attempts to stop may include

restricting in order to avoid binge eating or “the need to undo

damage” with purging. Anorexia - intending to increase intake,

but too fearful or unable to judge adequate amount. Repeated

attempts to restore weight marked by repeated periods of

relapse.

5– Increased time/activity/energy spent to obtain, use, and

recover

Common to all eating disorders – time, money, energy to

sustain eating disordered behaviors and increased time needed

to recover from effects

5

6– Social, occupational or recreational activities given up or

reduced

Common to all eating disorders – social isolation, as well

as, diminished activities that interfere with eating disordered

patterns.

7 – Use continues despite knowledge of adverse

consequences (e.g., failure to fulfill role obligations, uses when

potentially physically hazardous)

Common to all eating disorders – continued eating

disordered behaviors, despite physical, emotional, social, o r

financial consequences.

*DSM IV R- American Psychiatric Association/American Society of

Addiction Medicine

*Meeting a minimum of three criteria is sufficient for a diagnosis

of substance dependency [DSM IV-R]. DSM V-now defines a

substance use disorder with three subtypes: mild, moderate, or

severe. See: DSM V SUBSTANCE USE CRITERIA

In recent years the addiction model, at least as it applies to bulimia,

binge eating, and anorexia has been the subject of an expansive

6

body of research. A terrific summary of this appears in the newly

published text “Food and Addiction” edited by Kelly Brownell and

Mark Gold, Oxford University Press, 2012. The concentration of

this effort has ranged from an exploration of the nature of certain

properties of [mostly refined] foods to the neurobiology and

physiology of [eating disorders] addiction. There appears to be an

interaction between the nature of the substance [addicting or non-

addicting] and the nature of the person [addict or non-addict].

Hence, it is difficult to pin the blame only on the substance without

consideration of the person. For example, morphine is quite

addictive but not all patients receiving this drug to control pain

become “addicts.” Still others, who have a history of addiction, are

more vulnerable to becoming dependent on the drug. We know

today sugar and its’ many derivatives is addicting as a substance.

However, addiction to sugar is both dose and length of exposure

dependent, as well as, being influenced by the person consuming

it. This is to say it takes “two to tango” - with the substance needing

to interact with a predisposed and willing subject.

The most compelling evidence to date seems to have come to light

with the brain mapping capabilities of modern radiographic

imaging (PET Scan/brain imaging). Sparing the reader the technical

side of this, researchers have been able to locate and display areas

of the brain reacting to substances and stimuli in ways that

differentiate the addict from the non-addict. Furthermore, we now

7

better understand the “reward system” in the brain. We can clearly

see differences between dependent and non-dependent subjects.

Dopamine has been shown to be a primary “feel good” chemical in

the brain. Researchers have uncovered a stunning similarity

between chronic cocaine and stimulant abusers, and compulsive

eaters and bulimics – namely all have shown deficits in dopamine

concentrations and dopamine receptors on their PET scans. The

control subjects [non-addicts] did not display the same deficits. In

yet another study, the two groups were exposed to just pictures of

cocaine or, for overeaters, highly palatable desserts. The visual

cues alone caused a marked increase in dopamine activity among

the cocaine and ED subjects, but not so with their non-addict

peers. So, both an external cue [visual], as well as, the actual

consumption of the substance can elicit changes in brain

chemistry. This is what behaviorists call classical conditioning.

I’ve included an article I wrote summarizing the chemistry involved

with many eating disorders. The focus of the article looks at the

role of one of the basic neurotransmitters we spoke about –

dopamine. As mentioned, dopamine has been studied with respect

to its role in addiction. The progression from use, to abuse, to

dependency likely involves the interplay of amount, duration, and

individual predisposition – whether we speak of a drug or an eating

disorder.

8

Dopamine- th e “ Feel G ood Br ain Ch emi cal” *

In an article on the role of dopamine and dopamine receptors from

a March 2010 edition of "Neuroscience" - a well-known and

respected professional journal, the researchers found a significant

difference between laboratory animals that were "over-fed" and

exposed to unlimited amounts of sugar laden and highly processed

[junk] foods versus controls fed regular rat chow. Indeed, the junk

food rats developed an "addiction-like reward deficit" with

dopamine concentrations. The virtual destruction of D2 dopamine

receptors in the brain accounts for this.

Translation - over time, when overeating highly "palatable" foods

(e.g. sugar, high fat) they [rats] developed deficits in their ability to

properly assimilate the neurotransmitter dopamine. Deficits in

dopamine are seen with cocaine addicts when they are "crashing"

and withdrawing from cocaine - they become depressed and their

appetite becomes almost insatiable. Likewise, the deficit in

dopamine for binge eaters and bulimics tends to increase over

time with the result being a biological (addictive) propensity to

repeat episodes of disordered eating with greater frequency. Of

course we’ve come to know this phenomenon as tolerance. For the

bulimic, the misguided attempt to deal with this is purging or

alternating between periods of binge eating and restricting, for the

compulsive overeater, controlling this addictive cycle gives way to

9

another "diet". Whether this mechanism plays a role with forms of

anorexia is still a subject for speculation. I suspect the addictive

process with restricting is similar.

Much like the cocaine user who becomes an abuser and then an

addict, neurotransmitters (dopamine receptors) are eventually

destroyed. The only relief is...more cocaine for the fewer receptors

available. The phenomenon of tolerance takes hold and the addict

needs more of the substance to achieve the desired effect until no

matter how much substance is available it no longer works as it did

in the beginning stages. In fact, in most end stage addictions the

best one can hope for is to postpone withdrawal symptoms.

Addiction thus becomes a full-time career.

The "food addict" may begin abusing food and develops a similar

"tolerance" to refined carbohydrates (sugar, flour) or greater

volumes of food and, likewise, alters the brain's (reward) structure

(dopamine receptors) and the physical addiction to overeating

takes hold. A similar mechanism exists with purging, as applied to

endorphin metabolism. With anorexia the starvation process

creates a sort of tolerance as the body fights to survive and the

anorexic must restrict more and more to maintain the same effect

[e.g. avoid weight gain and control despair and anxiety]. There are

a few studies to suggest the stress hormone cortisol plays a role in

this process much like the neurotransmitters in the brain.

11

As with cocaine addicts, it's likely that over any extended period of

time, the mechanisms responsible for manufacturing and making

available dopamine at normal levels will re-emerge... provided the

"addict" adheres to a prescribed course of treatment (e.g. abstains

from the offending substance - cocaine or, for the food addict, the

combination of high-glycemic foods and over feeding [exorbitant

volume]. Likewise, proper nutrition and restoration of a

reasonable BMI would likely have a similar effect for the restricting

forms of eating disorders.

The first step in recovery is recognizing the importance of

abstaining from the offending substance[s] and behavior[s]. Those

with an eating disorder may need to consider a food plan that does

not evoke a physical craving. The current body of research suggests

the more highly processed a food substance is the more likely it is

to heighten the potential for abuse and dependency. The

exponential increase with childhood obesity and early onset

diabetes is directly related to this phenomenon. The evidence has

become overwhelming.

References:

Marty Lerner, PhD .2012 http://www.selfgrowth.com/experts/marty-lerner-phd Laboratory of Behavioral and Molecular Neuroscience, Dept. of Molecular Therapeutics - Published 3/2010 in Nature Neurosciences Neuroanatomy of Addiction, George Koob, 2012 in Food and Addiction by Brownell and Gold, Oxford Press, 2012

10

Dopamine, Brain Chemistry, and Anorexia

While we’re touching on the subject of the anorexic side of the

coin, I thought I might add some of the more recent thinking about

the role of brain chemistry and anorexia. There is a divergent group

of brain imaging folks who believe dopamine also plays a role in

disrupting the experience of hunger and appetite with those who

restrict.

There are basically two theories on the table today. The first

suggests overeating types of eating disorders involve dopamine

serving as the “reward” and feel good chemical released when

overeating. However, with the restricting forms of eating disorders

such as anorexia, the experience of increased dopamine

concentrations when eating is unpleasant. Hence, the feelings

associated with eating are negative for someone with anorexia and

rewarding for someone with compulsive overeating or bulimia.

Another group of scientists are looking into the effects of fasting

or restricting on dopamine levels for anorexics - the idea being a

similar surge of “feel good” dopamine, but this time stimulated by

restricting to the point of starving. In other words, there may be a

phenomenon for some people to “feel rewarded” by severely

restricting their calorie intake. Accordingly, the more one restricts,

at least in the early stages of anorexia, the more dopamine is

12

released, the more rewarded they are, and the more reinforced

restricting behavior becomes. No one knows why some are prone

to this end of the eating disorder spectrum as opposed to the

other. In sum, this hypothesis suggests that dopamine “rushes”

affect anorexics and overeaters alike, but for one group starving

releases the chemical and for the other binge eating does the trick.

Here is an excerpt from Walter H. Kaye, M.D., one of the

researchers at the University of California, San Diego who is

looking into the above theories. His comments also touch upon a

possible explanation for the body image distortions inherent with

anorexia.

“The reason (anorexics) can go on a diet and lose all weight is that

their brain is not responding in a way that is driving eating.”

Whether it’s not responding to the sensory aspect, it is not the

right signal about food, or it’s not rewarding, we don’t really

understand, but there’s something different about these

homeostatic mechanisms.”

“The area of the brain known as the insula, is important for

appetite regulation and also for something called interceptive

awareness, which is the ability to perceive signals from the body

like touch, pain, and hunger. It’s possible that some of the

problems anorexics have regarding body image distortion can be

13

related to alterations of interceptive awareness. There may be

some disregulation of insula function. This may, in part, explain

why a recovering anorexic can draw a self-portrait of their body

image that is typically 3 times its actual size.” To quote from

someone with this experience who is now recovering, “I was down

to 80 pounds at five-foot six,” she says. “My self-portrait was so

distorted I was able to lie down inside the drawing, but that’s how

I saw myself."

A reprint from an article published in Bloomberg News serves as

an excellent summary of the evidence pertaining to the addictive

nature of highly processed [junk] foods. Written by investigative

journalists Robert Langreth and Duane Stanford, the article

explores the social, economic, and biological impact of food

addiction and provides a rather convincing indictment of the

companies profiting from these products. Here is a [reprint] of the

Bloomberg article

The Case for Commercial Food Addiction

REPRINT- Bloomberg News, April 2011

Robert Langreth and Duane Stanford, investigative reporters

A growing body of medical research at leading universities and

government laboratories suggests that processed foods and sugary

14

drinks made by the likes of PepsiCo Inc. and Kraft Foods Inc. (KFT)

aren’t simply unhealthy, they can hijack the brain in ways that

resemble addictions to cocaine, nicotine and other drugs. “The

data is so overwhelming the field has to accept it,” said Nora

Volkow, Director of the National Institute on Drug Abuse.

“We are finding a tremendous overlap between drugs in the brain

and food in the brain.”

The idea that food may be addictive was barely on scientists’ radar

a decade ago. Now the field is heating up. Lab studies have found

sugary drinks and fatty foods can produce addictive behavior in

animals.

Brain scans of obese people and compulsive eaters, meanwhile,

reveal disturbances in brain reward circuits similar to those

experienced by drug abusers. Twenty-eight scientific studies and

papers on food addiction have been published this year, according

to a National Library of Medicine database. As the evidence

expands, the science of addiction could become a game changer

for the $1 trillion food and beverage industries.

If fatty foods, snacks, and drinks sweetened with sugar and high

fructose corn syrup are proven to be addictive, food companies

may face the most drawn-out consumer safety battle since the

15

anti-smoking movement took on the tobacco industry a generation

ago.

‘Fun-for-You’

“This could change the legal landscape,” said Kelly Brownell,

director of Yale University’s Rudd Center for Food Policy & Obesity

and a proponent of anti-obesity regulation. “People knew for a

long time cigarettes were killing people, but it was only later they

learned about nicotine and the intentional manipulation of it.”

Food company executives and lobbyists are quick to counter that

nothing has been proven with what PepsiCo Chief Executive Officer

Indra Nooyi calls “fun-for-you” foods, if eaten in moderation. In

fact, the companies say they’re making big strides toward offering

consumers a wide range of healthier snacking options. Nooyi, for

one, is as well known for calling attention to PepsiCo’s progress

offering healthier fare as she is for driving sales. Coca-Cola Co.

(KO), PepsiCo, Northfield, Illinois-based Kraft and Kellogg Co. of

Battle Creek, Michigan, declined to grant interviews with their

scientists. No one disputes that obesity is a fast growing global

problem. In the U.S., a third of adults and 17 percent of teens and

children are obese, and those numbers are increasing. Across the

globe, from Latin America, to Europe to Pacific Island nations,

obesity rates are also climbing.

16

Cost to Society

The cost to society is enormous. A 2009 study of 900,000 people,

published in The Lancet, found that moderate obesity reduces life

expectancy by two to four years, while severe obesity shortens life

expectancy by as much as 10 years. Obesity has been shown to

boost the risk of heart disease, diabetes, some cancers,

osteoarthritis, sleep apnea and stroke, according to the Centers for

Disease Control and Prevention. The costs of treating illness

associated with obesity were estimated at $147 billion in 2008,

according to a 2009 study in Health Affairs.

Sugars and fats, of course, have always been present in the human

diet and our bodies are programmed to crave them. What has

changed is modern processing that creates food with concentrated

levels of sugars, unhealthy fats and refined flour, without

redeeming levels of fiber or nutrients, obesity experts said.

Consumption of large quantities of those processed foods may be

changing the way the brain is wired.

A Lot Like Addiction

Those changes look a lot like addiction to some experts. Addiction

“is a loaded term, but there are aspects of the modern diet that

can elicit behavior that resembles addiction,” said David Ludwig, a

17

Harvard researcher and Director of the New Balance Foundation

Obesity Prevention Center at Children’s Hospital Boston. Highly

processed foods may cause rapid spikes and declines in blood

sugar and increased cravings, his research has found.

Education, diets and drugs to treat obesity have proven largely

ineffective and the new science of obesity may explain why,

proponents say. Constant stimulation with tasty, calorie-laden

foods may desensitize the brain’s circuitry, leading people to

consume greater quantities of junk food to maintain a constant

state of pleasure. In one 2010 study, scientists at Scripps Research

Institute in Jupiter, Florida, fed rats an array of fatty and sugary

products including Hormel Foods Corp. (HRL) bacon, Sara Lee Corp.

(SLE) pound cake, The Cheesecake Factory Inc. (CAKE) cheesecake

and Pillsbury Co. Creamy Supreme cake frosting. The study

measured activity in regions of the brain involved in registering

reward and pleasure through electrodes implanted in the rats.

Binge-Eating Rats

The rats that had access to these foods for one hour a day started

binge eating, even when more nutritious food was available all day

long. Other groups of rats that had access to the sweets and fatty

foods for 18 to 23 hours per day became obese, Paul Kenny, the

Scripps scientist heading the study wrote in the journal Nature

18

Neuroscience. The results produced the same brain pattern that

occurs with an escalating intake of cocaine, he wrote. “To see food

do the same thing was mind-boggling,” Kenny later said in an

interview.Researchers are finding that damage to the brain’s

reward centers may occur when people eat excessive quantities of

food.

Sweet Rewards

In one 2010 study conducted by researchers at the University of

Texas in Austin and the Oregon Research Institute, a nonprofit

group that studies human behavior, 26 overweight young women

were given magnetic resonance imaging scans as they got sips of a

milkshake made with Haagen-Dazs ice cream and Hershey Co.

(HSY)’s chocolate syrup.

The same women got repeat MRI scans six months later. Those

who had gained weight showed reduced activity in the striatum, a

region of the brain that registers reward, when they sipped

milkshakes the second time, according to the study results,

published in the Journal of Neuroscience.

“A career of overeating causes blunted reward receipt, and this is

exactly what you see with chronic drug abuse,” said Eric Stice, a

researcher at the Oregon Research Institute. Scientists studying

19

food addiction have had to overcome skepticism, even from their

peers. In the late 1990s, NIDA’s Volkow, then a drug addiction

researcher at Brookhaven National Laboratory on Long Island,

applied for a National Institutes of Health grant to scan obese

people to see whether their brain reward centers were affected.

Her grant proposal was turned down.

Finding Evidence

“I couldn’t get it funded,” she said in an interview. “The response

was there is no evidence that food produces addictive-like

behaviors in the brain.” Volkow, working with Brookhaven

researcher Gene-Jack Wang, cobbled together funding from

another government agency to conduct a study using a brain-

scanning device capable of measuring chemical activity inside the

body using radioactive tracers. Researchers were able to map

dopamine receptor levels in the brains of 10 obese volunteers.

Dopamine is a chemical produced in the brain that signals reward.

Natural boosters of dopamine include exercise and sexual activity,

but drugs such as cocaine and heroin also stimulate the chemical

in large quantities. In drug abusers, brain receptors that receive the

dopamine signal may become unresponsive with increased drug

usage, causing drug abusers to steadily increase their dosage in

search of the same high. The Brookhaven study found that obese

21

people also had lowered levels of dopamine receptors compared

with a lean control group.

Addicted to Sugar

The same year, psychologists at Princeton University began

studying whether lab rats could become addicted to a 10 percent

solution of sugar water, about the same percentage of sugar

contained in most soft drinks.

An occasional drink caused no problems for the lab animals. Yet

the researchers found dramatic effects when the rats were

allowed to drink sugar-water every day. Over time they drank

“more and more and more” while eating less of their usual diet,

said Nicole Avena, who began the work as a graduate student at

Princeton and is now a neuroscientist at the University of Florida.

The animals also showed withdrawal symptoms, including anxiety,

shakes and tremors, when the effect of the sugar was blocked with

a drug. The scientists, moreover, were able to determine changes

in the levels of dopamine in the brain, similar to those seen in

animals on addictive drugs. “We consistently found that the

changes we were observing in the rats binging on sugar were like

what we would see if the animals were addicted to drugs,” said

Avena, who for years worked closely with the late Princeton

20

psychologist, Bartley Hoebel, who died this year. While the animals

didn’t become obese on sugar water alone, they became

overweight when Avena and her colleagues offered them water

sweetened with high-fructose corn syrup. A 2007 French

experiment stunned researchers when it showed that rats prefer

water sweetened with saccharine or sugar to hits of cocaine --

exactly the opposite of what existing dogma would have

suggested.

“It was a big surprise,” said Serge Ahmed, a neuroscientist who led

the research for the French National Research Council at the

University of Bordeaux. Yale’s Brownell helped organize one of the

first conferences on food addiction in 2007. Since then, a protégé,

Ashley Gearhardt, devised a 25-question survey to help

researchers spot people with eating habits that resemble addictive

behavior.

Pictures of Milkshakes

She and her colleagues used magnetic resonance imaging to

examine the brain activity of women scoring high on the survey.

Pictures of milkshakes lit up the same brain regions that become

hyperactive in alcoholics anticipating a drink, according to results

published in the Archives of General Psychiatry in April. Food

addiction research may reinvigorate the search for effective

22

obesity drugs, said Mark Gold, who chairs the Psychiatry

Department at the University of Florida in Gainesville. Gold said

the treatments he is working on seek to alter food preferences

without suppressing overall appetite.

Developing Treatments

“We are trying to develop treatments that interfere with

pathological food preferences,” he said. “Let’s say you are addicted

to ice cream, you might come up with a treatment that blocked

your interest in ice cream, but doesn’t affect your interest in

meat.”

In related work, Shire plc (SHP), a Dublin-based drug maker, is

testing its Vyvanse hyperactivity drug in patients with binge-eating

problems. Not everyone is convinced. Swansea University

psychologist David Benton recently published a 16-page rebuttal

to sugar addiction studies. The paper, partly funded by the World

Sugar Research Organization, which includes Atlanta-based Coca-

Cola, the world’s largest soft-drink maker, argues that food doesn’t

produce the same kind of intense dopamine release seen with

drugs and that blocking certain brain receptors doesn’t produce

withdrawal symptoms in binge-eaters, as it does in drug abusers.

*Vyvance has since been approved for distribution by the FDA

23

for the treatment of Binge Eating Disorder as of 2015.

Industry Response

What’s still unknown is whether the science of food addiction has

begun to change the thinking among food and beverage

companies, which are, after all, primarily in the business of selling

the Doritos, Twinkies and other fare people crave. About 80

percent of purchase, New York-based PepsiCo’s marketing budget,

for instance, is directed toward pushing salty snacks and sodas.

Although companies are quick to point to their healthier offerings,

their top executives are constantly called upon to reassure

investors those sales of snack foods and sodas are showing steady

growth. “We want to see profit growth and revenue growth,” said

Tim Hoyle, director of research at Haverford Trust Co. in Radnor,

Pennsylvania, an investor in PepsiCo, the world’s largest snack-

food maker. “The health foods are good for headlines, but when it

gets down to it, the growth drivers are the comfort foods, the

Tostitos and the Pepsi-Cola.”

Little wonder the food industry is pushing hard on the idea that the

best way to get a handle on obesity is through voluntary measures

and by offering healthier choices. The same tactic worked for a

while, decades ago, for the tobacco industry, which deflected

24

attention from the health risks and addictive nature of cigarettes

with “low tar and nicotine” marketing.

Food industry lobbyists don’t buy that argument -- or even the idea

that food addiction may exist. Said Richard Adamson, a

pharmacologist and consultant for the American Beverage

Association: “I have never heard of anyone robbing a bank to get

money to buy a candy bar, ice cream or pop.”

To contact the reporters on this story: Robert Langreth in New York at rlangreth@bloomberg.net; Duane D. Stanford in Atlanta at dstanford2@bloomberg.net

Closing Thoughts – The Nature of th e “ Beast ”

I’ve chosen a few articles to articulate the physical addiction thesis

representing a sample of what is now appearing in the scientific

literature. One might then assume it reasonable to give

consideration not just to the amount of food prescribed, but its

possible effects on the body. As mentioned, addiction is a complex

interaction between substances and individuals. There is both a

potential for physical dependency, as well as, a psychological one.

Despite the fact people with an eating disorders may vary as to

which of these plays the greater role, suffice it to say both must be

addressed.

25

Likewise, we need to acknowledge the addictive nature of

restricting and the compulsive pursuit of weight loss and resulting

fears surrounding weight gain seen with anorexia. Here the nature

of the substance, food in this case, may be less a factor than the

psychological and physical effects of restricting and resultant

weight loss. However, I would suggest consideration of both the

quantity, as well as, types of food prescribed are equally

important. Given the risk of replacing one form of an eating

disorder for another, a recovery program giving credence to the

characteristics of foods tends to minimize some of this risk. Yes,

quantity is important, but so is the integrity of the food. Programs

encouraging participants to consume “high calorie” foods to insure

rapid weight gain may be setting someone up for developing yet

another form of their disorder. Furthermore, there are other

physical consequences of rapid weight gain and an ill-advised re-

feeding protocol – some of which can be life threatening.

For the compulsive overeater and the like, including controlled

portions of junk foods into the food plan carries the risk of giving

short-term success followed by a full blown relapse back into the

eating disorder. Some might argue this point, but I would suggest

it's similar to teaching an alcoholic controlled drinking. He or she

might be successful in a structured setting for a period of time, but

in all likelihood, experience an even worse problem than they had

before beginning treatment.

26

Like many addictive diseases, someone with an eating disorder is

prone to “negotiate” with their disease and, in effect, only change

its' form. Examples of this phenomenon abound in the addiction

world. An alcoholic gives up drinking by replacing alcohol with

tranquilizers. Giving up cocaine, someone resorts to “only smoking

pot.” The compulsive gambler pledges to only “invest” in the stock

market or to only buy a lottery ticket. No longer restricting, the

anorexic begins compulsively exercising to “make up for” the

increased calories consumed while rationalizing they are no longer

starving themselves. Further, the bulimic sufferer can be deluded

into thinking they have found the solution to binging and purging

by restricting. Of course this tends to lead to an even worse relapse

sooner or later.

In my experience, most people with an eating disorder will

eventually experience different forms of the illness throughout the

life cycle of their illness, until they find their footing in recovery.

Regardless of their body weight or appearance, most go through a

bulimic phase, a restricting one, and a compulsive overeating stage

over the course of their disease. For example, someone suffering

with bulimia believes by restricting and not “needing” to purge,

they’ve solved their bulimia problem. Trading in bulimia to become

anorexic is not recovery and vice versa. The denial factor usually is

analogous to trading deck chairs on the Titanic in an effort to avoid

drowning.

27

The bottom line here gets down to recognizing the addictive

nature of an eating disorder and at the same time, accepting the

need for more than a one-sided approach to treatment. To be

clear, the need to respect the addictive nature of certain foods, as

well as, the relentless focus on body weight or body image is a

necessary beginning. However, a program of recovery that limits

itself to only the food and weight piece of the puzzle will likely land

short of the mark. To paraphrase our beloved friend Albert

Einstein, “the same mindset that created the problem cannot be

the same one that formulates the solution.”

Additional References and Suggested Reading:

• Brain Chemistry, Robert Lefever, M.D. and Marie Shafe, Ed.D.Reprint available upon request via mlerner@MilestonesProgram.Org

• Opiate-like effects of sugar on gene expression in reward areas of the rat brain, Spangler, R., Wittkowski, K.M., Hoebel, - Laboratory Of Behavioral Neuroscience, The Rockefeller University, N.Y., N.Y. 2004 Reprint available upon request via mlerner@MilestonesProgram.Org

• Anatomy of a Food Addiction, Anne Katherine Text available for Purchase via Amazon.com or Milestones Bookstore

• Food and Addiction, A Comprehensive Handbook, Edited

by Kelly Brownell and Mark Gold, Oxford Press, 2012 Text available via Oxford Press or Amazon.com

28

Chapter Two Common Denominators for Eating Disorders

"Everyone is kneaded out of the same dough, but not baked in the same oven."

Yiddish Proverb

29

Def i n in g th e Prob l em…

Ok, let’s take a moment and “think outside the box” and ask what

all these different “flavors” of disordered eating have in common

rather than what separates them? Is it not true most people, even

medical and mental health professionals, tend to identify and

define an eating disorder in terms of how someone looks or how

overweight or underweight they appear? After all, how can one

suffer with an eating disorder if they don’t appear eating

disordered? And, how is it possible someone can admit to having

an issue with abusing food, excessive dieting, or compulsive

exercising, and not show outward signs?

Even more striking is this perception is too often supported by

many of the treatment programs and self-help groups intended to

help people find their way into recovery. In effect, this seems to

overshadow the fact that, recovery is about more than just

changing someone’s weight or eating behavior. For most people

with a bona fide eating disorder, body weight and body image

perception are a set of symptoms and [excuse the pun] not the

whole enchilada. Fact is, not all underweight people suffer with

anorexia and not all overweight people suffer with a binge eating

disorder. Suffice it to say there may be a difference between a

weight disorder and an eating disorder. Again, I refer the reader to

31

the APA guidelines [criteria] for dependency to delineate between

a weight problem and an eating disorder. (See Chapter One)

It would seem many people who do not have first-hand experience

of an eating disorder “miss the boat” in this respect. Truth be told,

this is similar to what most people once believed about alcoholism

and drug addiction: alcoholics all wear sneakers, trench coats, and

live under bridges, while all drug addicts live on the streets and

steal money for drugs, and so on. We know differently today. The

overwhelming majority of chemically dependent people cannot be

“picked out of a crowd.” That said, I’d suggest we revisit the

stereotypes many of us have with respect to eating disorders.

This leads us to a retooling of the defining characteristics of all

eating disorders and an assumption I would present to the reader

for consideration.

Eating Disorders are best defined by the degree the relationship

with food and/or body image diminishes the quality of

someone’s life.

A helpful suggestion for newer members of 12-Step programs is to

“identify and not compare.” The reasoning behind this suggestion

is to not provoke the newcomer into a form of denial by telling

themselves something along the lines of “I’m really not as bad as”

30

or “I don’t do what they do every day.” I suspect we could go on,

but you get the idea. The “identifying” piece is about relating to

the experiences and feelings of the other members. To be clear,

anyone suffering with an eating disorder can relate to the feelings

of despair after repeated attempts to “control” their addiction.

Both the anorexic and the compulsive overeater can relate to the

feelings of shame and fear, as it relates to their discomfort with

their body and relationship with food.

What binds people together is more relevant to recovery than

finding what’s unique or different about them. This places

everyone on equal footing regardless of age, gender, social status,

race, religious background, etc. In the end, the common thread

that runs through the community at Milestones has to do with

seeing similarities, not differences and an honest desire to find the

way to recovery. Understanding that as a group, they are able to

do for the individual what they were not able to do alone, is one of

the most important concepts within a therapeutic community.

There is a collective energy, or if you will, a power greater than the

individual at work here.

“ I f i t w al ks li ke a d uck….”

Just about anyone who has attended a support group such as OA*

or ABA* for a few weeks will likely hear “their story” told by

32

another member. The effect of one person’s experiences shared

with a fellow having the same experiences is, to quote a related

program, “unparalleled.” Once the initial layer of the onion is

peeled, namely the “what makes me different than these people,”

the stage is set for identification rather than comparison. The

question then becomes, “so what do I have in common with

everyone here?” From that point forward, the focus begins to

center more on the solution – “what do I need to do to recover?”

Doing otherwise leaves someone with over analyzing the problem

and little energy left to begin work on the solution.

*Overeaters Anonymous [http://www.oa.org] *Anorexics and Bulimics Anonymous [http://aba12steps.org/]

Aside from meeting at least three of the criteria for dependency

we read about in the previous section, eating disorders tend to

have in common the relentless attempt to control how we feel.

Although we’ll look at this more in depth in the next section, I

would suggest that all eating disorders are motivated by an intense

desire to fix or avoid an unpleasant feeling. Although the feeling

may vary within and among persons, the end game remains the

same – control, fix, and change the feeling / discomfort du jour.

One variant on this theme comes from a summary statement made

by a very famous psychoanalyst, Carl Jung. Although I may be

33

accused of butchering his quote for the purpose of making a point,

let’s look at what Carl said:

“All neurotic behavior is an attempt to avoid legitimate

suffering.” – Carl Jung

Restating his rather astute observation, I would suggest…

“Addictions are an attempt to avoid legitimate suffering and, by

this line of reasoning, eating disorders become another way to

avoid legitimate suffering” –

Jung was referring to the symptoms of “his neurotic patients". Let’s

take the compulsive hand washer and his constant fear of germs.

For Carl Jung, this often represents a person’s attempt to control

germs because he is unable or unwilling to admit feeling out of

control in other areas of his life. Perhaps a stretch for some of you,

but consider how often a ”habit” like smoking, biting your nails,

compulsively shopping, or overworking is really a means of

avoiding or distracting us from something uncomfortable and

beyond our control. Again, the point is we often engage in

potentially compulsive or addictive behaviors in a misguided

attempt to “manage” unpleasant feelings. The notion of accepting

rather than immediately “fixing” our discomfort is foreign to many

of us.

34

Over time, too much avoidance and distraction have the potential

of becoming addictive, as our tolerance for discomfort becomes

less and less and our need to find relief grows stronger. Unless we

find a more appropriate and less destructive means of reacting to

“legitimate suffering” we are prone to creating a number of

compulsive and addictive behaviors.

Although I would hardly count myself in the same category as Carl

Jung, I do believe he was on to something back in his day. After all,

people do not starve themselves, make themselves sick, take

handfuls of laxatives, binge eat until they’re in pain, exercise to the

point of exhaustion, or engage in any number of painful actions

unless they are attempting to avoid or change their emotional

state. As mentioned, what we see with eating disorders is a

progression of first attempting to feel better followed by an

attempt to delay or avoid feeling bad [withdrawal] in the later

stages. I’ve seen this to be as true for someone in the midst of

anorexia as someone struggling with a binge eating disorder. The

same can be said for almost all addictions.

Another similarity within the ED population has to do with the

incidence of coexisting mood disorders. More often than not

recurring depression, anxiety, and marked mood swings come with

the territory. In addition, more than half the people seeking

treatment have histories of abusing alcohol, drugs, and/or other

35

forms of self-abusive behaviors like cutting. Regardless of the

particular eating disorder, it’s rare to see someone with an ED

without an accompanying mood disorder, chemical dependency,

or self-abuse issue.

Table 2.1

Similarities among the Eating Disorders

- The majority of people with an ED meet the established

criteria for [addiction] dependency per the same criteria

typically reserved for substance dependencies*.

- ED behaviors are initiated in an attempt to avoid or change

uncomfortable feelings - usually negative feelings and

emotional states.

- Most eating disorders typically are associated with a mood

disorder that often pre-dates the beginning of the eating

disorder.

- Regardless of ED type, at least half the people coming to

treatment for an ED also have abused alcohol, drugs, or

relied on additional forms of self-medication.

36

- Having an ED makes someone vulnerable to “switching

addictions” throughout the life cycle of their ED.

- Independent of the form of ED, control issues are a central

theme needing to be addressed – first with food and

weight, and later with other areas of daily living such as

relationships.

- With the exception of some subtypes of anorexia, most

people suffering with an eating disorder react to certain

foods [e.g. sugar derivatives, refined flours, highly

processed junk foods, etc.] differently than their non-

eating disordered peers. *see D2 receptors and eating

disorders

- Both psychological and physiological factors are inherent

among all forms of eating disorders. Physical dependency

and psychological dependency interact to create an

addictive relationship with food, body weight, and/or

dieting.

- Long-term recovery from an eating disorder requires

significantly more than a temporary change in someone’s

body mass index [BMI / weight / appearance] and eating

pattern.

37

- Recovery often requires the ongoing participation in a

support group or a continuing care plan after formal

treatment ends.

- Appropriate [non-habit forming] medication[s] usually are

needed to treat co-occurring depression or a similar issue

accompanying an eating disorder. In many instances, the

mood disorder is a “stand alone” diagnosis that exists with

or without the ED.

- Most people with an eating disorder have some level of

impairment with an ability to differentiate between

hunger [physical needs] and appetite [psychologically

driven]. – internal versus external cues of hunger

- As with other addictions, remission is a more realistic

expectation with treatment outcome rather than a “cure.”

In effect, addiction is a life-long disease that can be

arrested by remaining engaged in consistent recovery

related activities. Remission can be life-long or short-term.

Co-Existing Addictions and Related Problems

Those of us who have been in and around the recovering

community are quite aware of the prevalence of eating disorders

within the fellowships of Alcoholics Anonymous, Narcotics

38

Anonymous, and related 12-Step groups. This recognition of the

correlation between eating disorders and addictions - chemical

dependencies and process addictions* alike, is gaining increasing

attention in the popular press and research literature.

Although there are no exact figures, a conservative estimate of the

percentage of chemically dependent women who would “qualify,”

as eating disordered likely is in the neighborhood of twenty to forty

percent. There are no gender-specific studies regarding “cross-

addiction.” However, there is evidence to suggest that, of all the

cases diagnosed in the general population, at least ten percent are

male. Certainly, when we speak of “disordered eating,” we are

including all those suffering from the most widely recognized

eating disorders including anorexia, bulimia and binge eating

disorders. Although many individuals suffering with an eating

disorder may appear significantly overweight or underweight, like

most alcoholics and drug addicts, one cannot identify someone

with an eating disorder simply by appearance. *Process addictions

include compulsive gambling, shopping, sex, and those thought to

involve habitual patterns of behavior and not attributable to a

drug, chemical, or other substance.

When we look at an addiction, and in this case we’re looking at

eating disorders, we’re really apt to discover the existence or

predisposition toward another dependency – if not several. One

way to conceptualize this cross addiction phenomenon is depicted

39

in Table 4.1. The table represents a hypothetical list of other

addictions that may or may not be secondary to the eating

disorder. These may be co-existing at the time of treatment or

represent prior forms of self-medication or addiction. This

particular pyramid is fairly representative of the collective issues

often seen in the treatment setting, coinciding with an eating

disorder. Naturally, there are individuals that do not fit this model

and come to treatment with no history of co-existing addictions.

However, such folks would be well advised to be on the lookout for

the potential to exchange the form of their eating disorder or

develop a new dependency in the course of their ongoing recovery.

TABLE 4.1 – Sample – The Addiction Pyramid

EATING DISORDER

CHEMICAL DEPENDENCY

C O - D E P E N D E N C Y

N I C O T I N E / C A F F E I N E

G A M B L I N G / C U T T I N G / S P E N D I N G

Interspersed with co-existing addictions and related forms of self-

medication are mood disorders. The most frequent of these

include recurrent depression, anxiety disorders such as panic

disorders, phobias, generalized anxiety, and bi-polar disorder. The

prevalence of mood disorders associated with an eating disorder

is estimated to be in the range of 80% or more. This is greater than

41

any other addiction including drugs, alcohol, or any of the process

addictions. Very often a combination of the appropriate therapies

is necessary to treat these issues at the same time as addressing

the eating disorder. Regardless of whether a mood disorder pre-

dates the beginning of an eating disorder or came about as a result

of one, it’s imperative to diagnose and treat it.

As a point of information, the majority of patients presenting with

a depressive disorder usually identify their depressive symptoms

as predating the onset of the eating disorder. In such instances the

depression may be considered an independent illness and, if left

untreated, will likely persist beyond the treatment of the eating

disorder. The implications are two fold – first, the medication piece

may need to be life-long as the diagnosis is one of recurrent

depression and not a single episode and, second, the continuation

of the medication is one of minimizing the risk of recurrence of

another depressive episode and relapse back to the eating

disorder. Still another group of eating disorder patients present

with depressive symptoms directly related to the eating disorder

and, as such, represent a single episode of depression or

depression secondary to their eating disorder. For this group,

medication can be recommended for periods up to a year or so

with the depressive symptoms improving significantly with the

remission of the eating disorder. However, unlike recurrent

depression, antidepressant medications are not necessary for

long-term maintenance of recovery with this group. A

40

conversation with the prescribing physician regarding your history

and diagnosis, apart from the eating disorder, will help you

understand what needs doing on the medication front.

Defining - Medication or Drugs?

It may be helpful to delineate between using medication and using

a drug. Medication is intended to put people on a par with reality

and capable of benefiting from other forms of therapy. Drugs tend

to dull a sense of reality and usually are taken to deaden or alter

feelings. Some prescription medicines can be abused as drugs,

such as stimulants intended for attention deficit disorders, but are

used instead to get high, while others are of great benefit when

taken as directed. * Medications, then, can be a tool in recovery or

misused as a means of furthering ones’ disease. In fact, the same

prescription drug can be used as a medication for one person and

as a recreational drug or “diet pill” for another.

The more frequent diagnoses and issues accompanying an eating

disorder are shown in Table 4.2. These represent a sample of

issues we frequently see at our facility, as well as, what other

programs need to consider with ED treatment.

42

TABLE 4.2 – Dual Diagnoses + ED

- Alcohol Abuse and Dependency

- Major Depression - recurrent and single episode

- Bi-Polar Disorder

- Anxiety Disorders – phobia and generalized Anxiety

- Drug Dependency - Prescription Meds, Street

Drugs, etc.

- Alternating Eating Disorders – Binge Eating > Bulimia

- Nicotine Dependency

- Borderline Personality Disorder

- Obsessive Compulsive Disorder

- Process Addictions – Compulsive Gambling, Shopping, Sex

- Impulsive Control Disorders - Shoplifting

- ADD – with or without hyperactivity

43

Cross Addiction and Co-Existing Issues

The take away from this topic is simply to recognize addictions and

compulsions are often misguided attempts to manage or control

our feelings. That being the case, it would seem likely when we

stop using one means of doing this we’re prone to “go back to the

well” and rely on another. The important thing here is to accept

the need to work on the problem [nature of the person] and not

just the symptom [the addiction]. Be patient, be cautious, and be

honest with yourself. Some of these issues can be tackled along

with your eating disorder treatment and some will be taken on

later in the course of your recovery. Which one and when will

depend on how they threaten your eating disorder recovery and

whether you can “buy time” to work on them at a later date.

Body Image and Body Dysmorphic Disorder

I’ve always been fascinated by the “disconnect” between how we

experience our speaking voice and how it sounds when we listen

to it from a recorded device. Likewise, there’s the tendency to view

different photographs of ourselves and wonder how we could look

so different in each one, yet almost everyone else hardly notices

any change. How can we see the same picture so differently from

others? Is it possible our perception is influenced by factors we’re

not totally aware of? To be clear, this phenomenon of perceiving

and experiencing ourselves differently from the “outside world” is

44

common to all human beings. The issue, however, rests with the

tendency among many people exaggerating this “discrepancy” in

the service of self-criticism and a distorted sense of self. Few

populations exemplify this distortion of reality as those suffering

with an eating disorder.

Body image distortion, as it relates to eating disorders, and its

“cousin”, body dysmorphic disorder, is perhaps the most

pronounced example of how these “disconnects of perception””

dominate the thoughts and feelings of ones’ daily life. To illustrate

this “in the eyes of the beholder” phenomenon, many of you may

be familiar with the “old or young woman” optical illusion (see next

page).

Although there may be an infinite number of “theories” as to how

the brain processes the physical world vis-à-vis our senses, the fact

remains there is no clear cut understanding to account for the

relentless perception of either an undernourished or healthy body

being overweight, or a pop star enlisting an army of surgeons to

alter his nose repeatedly until he must wear a mask in public. At

the very least, it would be reasonable to say many of those

suffering with anorexia, bulimia, and in many cases binge eating

disorder, have in common some degree of “confusion” as to how

they really appear.

45

What do you see? Is it a profile of a young

and beautiful lady, or do you see an old

woman with a huge and ugly nose?

Body Image and Body Dysmorphic Disorders

are typically not about vanity per se. Fact is, body image issues can

be found in all subtypes of eating disorders, although most

commonly associated with anorexia. As we’ve seen, eating

disorders are often associated with people with exaggerated needs

for control, perfectionism, and insecurities that appear to focus on

appearances. To be sure, there is a difference between someone

with a “weight problem” and one with a bona fide eating disorder.

The latter usually having to deal with the confusion over perceived

body image and a pathological relationship with food and weight.

Most of the “dieting off and on” folks do so without a serious

disruption to their lives. They are what some refer to as the

“worried well.” Such is not the case with an eating disorder. That

being the case, let’s look at one hypothesis.

Through the years, I’ve come to experience mood disorders, in

particular forms of depression, as the “chicken before the egg”

regarding body image and body dysmorphic disorders. In reality, it

is more the rule than the exception that a mood disorder

accompanies, if not “pre-dates” the onset of an eating disorder. To

be clear, our mood will more often than not color our perception.

In other words, the more depressed, the more negative our view

46

of ourselves. The “smoke and mirrors” effect of an eating disorder

then goes something like this: “I look in the mirror and I see myself

as and that’s what really makes me feel depressed. If I were

able to change the way I look then I wouldn’t be so depressed.”

Hence the anti-depression fix becomes changing the body or

numbing the pain with further restricting or binge eating, etc. The

angst of how we experience our body is believed to be the problem

and the solution becomes changing the body at any cost – even to

the point of engaging in life threatening behaviors.

I’m not proposing the solution to a body image issue is simply

“buying into” this theory or finding the right “medication.” What I

would suggest is at a minimum conceding your “perception” is a

confused one and giving consideration to putting your energy into

a recovery process. That process would give equal time to

following a treatment plan that includes a healthy food plan,

abstaining from your eating disorder behavior[s], with professional

help if necessary, and also finding a way to appropriately manage

your depression. Last, but not least, I would be remiss not to

mention that more than half of the people we see at Milestones

also have relied upon alcohol, drugs, or other compulsions in

addition to their ED in a misguided attempt to “control” their

depression and perceptions.

In sum, body image disturbances are a prominent feature of most

eating disorders. Whether they are a symptom of an underlying

47

issue with a mood disorder such as depression or generalized

anxiety disorders, a manifestation of past trauma, or any number

of factors often associated with eating disorders may not be

important. What matters is the need to acknowledge body image

disturbance as a symptom of the disease – more so for some, and

less so for others. Another point to consider is resolving the

depression or underlying mood disorder does not guarantee the

resolution of a distorted or negative body image. That said feelings,

thoughts, and perceptions about our body become less

troublesome over time if following a recovery program. By

incorporating the principles of a 12-Step program and some of the

principles discussed, we can learn to live with our imperfections.

The frequency and intensity of negative experiences with our body

will diminish. Self-focus and a renewed interest in other people

and things beside ourselves will usually follow.

Internal and External Cues: What also makes us different?

My experience has been eating disorders almost uniformly involve

a broken thermostat-like mechanism that governs internal cues

[symptoms] of hunger and fullness. In other words, unlike our

“normal eating” contemporaries, we are often confused when to

eat, what to eat, how much to eat, and/ or when to stop eating.

Whether suffering with anorexia, bulimia, or compulsive

overeating, there is a tendency to be more governed by external

stimuli - such as the sight of food, smells, time of day, stressful

48

events, body image, etc. These influence our behavior around food

more than the internal cues such as blood sugar levels, stomach

contractions, an empty stomach, and so on. Just how much do

these factors mediate our eating behaviors?

We seem more susceptible to being conditioned to associate

certain emotions or external events with turning on or off our

appetite. Again, another way to look at this may be that our

circumstances and psyche tend to “trump” our physical needs or

internal signals when it comes to our eating. To date, science has

yet to figure out whether this is a learned behavior or one some of

us prone to eating disorders are born with.

Given both the effect certain foods exert on our brain chemistry

and this external orientation regulating our appetite, we need to

have a plan to take both factors into consideration. Again, there is

the nature of the person and the nature of the substance

interacting here.

The “plan” needed begins with some structure and realistic

boundaries around our eating. In my humble opinion, it is why an

“intuitive eating” approach is not the best route to take with food

planning and eating in general. There is a need for limits around

the types of foods we eat, a reasonably consistent schedule of

when we eat, and an acceptance of some of the physical and

49

psychological differences that separate us from our “normal

eating” peers. The same can be said for people suffering with a

variety of other substance and process addictions. Although the

differences may be unique to their particular problem, they too

differ from their non-dependent peers. By way of example, allow

me to tell you a little bit about my friend Harry.

My Fr i en d Harr y….

Everyone with an eating disorder has known a Harry or Harriet, if

you prefer. You know the type. Harry never worries about weight

or what he eats. Perhaps you sit at the local diner staring at the

“low calorie plate” in front of you - typically an all-beef patty

without the bun, a wilted piece of lettuce with a scoop of large curd

cottage cheese atop a pear half with a Diet Coke - and glance across

the table at your friend Harry. There’s Harry with his cheeseburger,

fries, and a cherry coke. As an evil fantasy crosses your mind of a

sudden and painful demise for Harry, you quietly slide the

remainder of his meal over to your side of the table, while

paramedics work to restore his pulse. As you finish the last fry and

take the final bite of his burger, you gently place the bill in his

lifeless hand and tell the server “he’s got the check.” Suddenly

you’re startled from your daydream when the waiter returns and

asks,“anyone want dessert?” Harry replies, “How’s the

cheesecake today? What a nightmare.

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Ever notice your “Harry or Harriet” taking a “taste” of the cake and

leaving it at that, or perhaps pushing away their half-finished plate

because “they’re full”? Chances are Harry relies more on his

internal guidance system than being led around by all the external

stuff. With eating disorders this guidance system is pretty much

broken. It's not so much that Harry has a “better metabolism” than

you. Fact is our friend’s behavior around food is not hijacked by all

the external and emotional stuff the way we are.

Growing up, I remember when my mother would become nervous

or agitated over something she would tell us “I’m so upset I can’t

even think about food.” Sounds like she’s a Harry or Harriet type.

Although that may be the case for some people, lots of us might

have the opposite reaction, soothing ourselves with “comfort

foods.” Still others would find it not only difficult to eat when

upset, but also find the act of eating by itself unsettling. We’re

looking at emotional eating or restricting as a reaction to events

and stimuli outside ourselves, hence, external cues and

perceptions trumping our biological cues.

A Quick Footnote about Harry….

By the way, Harry also habitually left over half a Martini and

seemed to be able to “take or leave” most things that people

usually consume. In fact, Harry never seemed to become too

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dependent on anything or anyone. Imagine that! Oh well - maybe

in the next life.

The Restricting Side of the ED Coin

Then again, you may be at the other end of the eating disorder

spectrum. With more of an anorexic pattern, there is either a

denial or misinterpretation of our physical needs or, more

typically, a phobia of what will happen to us if we “give in” to our

hunger and feed ourselves. The “phobic” response to eating and

the never ending pursuit of being “thin enough” seems to come

with the territory. Fact is, there is a general mistrust of what the

body is telling us internally and an over reliance on external

perceptions and stimuli that further our “Dis-Ease.” Even when

“listening” to your body, you’re likely to continue to mistrust both

the message and the messenger.

In sum, over feeding and under feeding are simply different sides

of the same coin. Both are perpetuated by a chaotic array of mixed

messages from our internal selves and what we perceive on the

outside. All this makes for a relentless battle between our bodies

and our minds. Not a fun place to be.

One of the positive outcomes of recovery comes when we accept

we are not a Harry or Harriet type. In some circles this is referred

52

to as a cucumber becoming a pickle never to return to being a

cucumber again. Being a pickle, however, does have its

advantages. With acceptance of our reality, the adoption of a

reasonable food plan becomes a preferred place to be rather than

a prison sentence. *Clean eating, along with the other components

accompanying a recovery lifestyle become a matter of preference

and not something we do because “we have to.” You’ll find the

same experiences among people enjoying long-term recovery

from alcohol, drugs, and other dependencies - namely their

“recovery” has become a blessing and not a curse. I’d further the

analogy to someone with any chronic disease. If we we’re

discussing diabetes treatment then eating within the bounds of a

healthy whole-food plan, moderate exercise, managing stress, and

developing a personal sense of spirituality would be the exact

prescribed program called for. If you think about it, this formula

would serve anyone with a chronic disease and go a long way to

restoring someone’s health and quality of living.

[*]It’s important to remind the reader our reference to “abstinent

food plans” and “clean eating” are about healthy and adequate

nutrition and not in the service of further restricting calories.

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A n d th e Goo d New s I s…

The good news is long-term recovery from an eating disorder is

entirely possible. The bad news is it requires hard work. Following

the right course of treatment, following an appropriate recovery

program, adherence to a healthy food plan, and addressing the

problems often accompanying an ED, are key to achieving this goal.

Few do it alone. There is a roadmap, a way out of the woods, so to

speak.

I often suggest to people engaged in the treatment process at

Milestones to consider doing as near 100% of what is being

suggested as possible. Those doing their best will likely take with

them enough of what’s needed to stay in recovery. However,

should someone be cutting corners, modifying and devising their

own version of a treatment plan – namely doing only what they

believe applies to them, they usually end up in relapse either

before or shortly after they finish treatment – or they leave with

only a “diet” instead of program for recovery.

That being said, the primary purpose of this text is to set the stage

for recovery. Doing so first necessitates defining the problem.

Hopefully we’ve made a reasonable start in doing just that. Next is

asking yourself if you’ve reached the point of willingness –

specifically to commit your energy and faith into “living in the

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solution” rather than staying stuck in the problem. Should you be

at that point, the suggestions and information forthcoming will

help you get where you want to go.

**********

Additional References: Available upon request mailto:mlerner@Milestonesprogram.Org

What comes first, the Chicken or Egg? – Wh y, It’ s th e Egg!

There is a physics experiment that may serve as a metaphor for

recovery. This demonstration is intended to prove it possible to

place our recovery first and still have time to get everything else

done. If I can borrow your imagination for a few minutes you’ll see

what I mean.

First picture a large Tupperware Bowl, with the lid off, filled with

uncooked rice, about a half inch from the top. The rice symbolizes

all the stuff we need to get done on any given day – the laundry,

preparing meals, going to and from work, our jobs, getting our hair

done, feeding our dog, cat, or kids, going to the dentist, taking a

shower, getting the oil changed in the car, and on, and on, and on.

Next, take four hard-boiled eggs. Each egg now represents one of

the four basics of recovery - S.E.R.F. Please make sure the eggs are

hard boiled so they don’t make a mess. Place the eggs on top of

the rice and try and close the lid. It won’t close. So… you eliminate

one of the eggs. Still won’t close. Ok, you take away another one,

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no cigar. Eventually you might get it to close with one or two eggs

left. Not much recovery left here. Maybe your SERF is reduced

to EF.

And now…. Take an identical size bowl that’s empty and place it

next to the original one. Now take all four [SERF] eggs and place

them in the empty bowl FIRST. Now pour the same rice from the

original bowl over the eggs on the bottom. And, finally, place the

lid on the bowl. Guess what – it fits.

Believe it or not, this is something we actually do as a

demonstration from time to time at Milestones. In reality, we’ll

find ourselves with more than enough time to take care of what

needs doing when we put our recovery first and allow the rest of

our daily stuff to fall into place. Being consistent with the SERF

basics is one of the paradoxes of recovery – namely putting

ourselves first-positions us to better take care of everything else.

As has been mentioned repeatedly throughout this guide Doing is

Believing.

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Chapter Three Recovering from an Eating Disorder

"Some of us think holding on makes us strong,

but sometimes it is letting go."

-Herman Hesse

57

The Roadmap

When all else fails, follow the directions” – anonymous

Ok, now we’ve come to the instructions. You know, the written

materials [aka instructions] most people either discard or only

glance at while putting together whatever it is they’re trying to put

together. If you’re like me, you usually end up with a bunch of parts

left over and something that doesn’t quite look like the picture on

the box. This may be a time to do it differently. A word of caution

- it’s not unheard of for people with, shall we say, control issues,

to be slightly defiant and a tad bit stubborn [a little sarcasm here].

If this doesn’t apply to you then I would suggest you may be in the

wrong place or, more likely, are having one hellacious issue with

denial. Fact is, most people who suffer with an eating disorder,

have more issues with control and trust [what a surprise] than their

non-addict peers. These two issues are a central theme of what

needs to be addressed in the recovery process. We’ll talk about

control and trust in a few pages.

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A Word About “T h er ap y”

“So What, Now What?” - unknown

Least we’d be remiss if we didn’t provoke a little controversy here.

Allow me first to confess to being someone with both professional

and some personal experience with eating disorders and

addiction. This leaves me with a distinct, and perhaps subjective

take on what works and doesn’t work. Likewise, our clinical team

at Milestones has come to appreciate a similar perspective. That is

to say the approach to recovery that works best is one of teaching

the skills needed to keep it. Doing so does, however, require

putting these skills into practice on a daily basis. The saying that

best describes this philosophy is simply “teaching someone how to

fish is far better than feeding them a fish.” Hence the goal is doing

recovery rather than knowing about it.

W h at Wor ks an d Doesn ’t W or k?

“Quitting is easy; I’ve done it countless times.” - unknown

Let’s begin with what doesn’t work. Traditional forms of

insight oriented, psychoanalytic, and various other therapies

relying on a revisiting and reframing of the past are among the

least promising approaches. In other words, coming to

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understand what “caused” your eating disorder and

“connecting the dots” has little effect on a successful outcome,

unless it directs someone to take action in the present.

Through the years I’ve come to know a number of people

struggling with anorexia, bulimia, binge eating, and a number

of other related issues. Almost all had some form of traditional

counseling or therapy prior to coming to a residential program

like ours. With few exceptions, they had tons of insight as to

when, where, why, and how their addictive relationship with

eating or dieting began. For some it was related to control

issues, using their need to control food and weight in lieu of not

being able to control other parts of their lives. For others it

had to do with a misguided attempt to deal with a traumatic

event such as sexual or physical abuse. The list can sometimes

be endless. Perhaps the question one should ask is “so what, now

what?”

Their accounts suggest self-medicating with food or restricting

after developing a deep sense of distain for their bodies. In the

end, identifying the causes had little to do with overcoming their

ED. In my opinion, by the time someone reaches the point of

wanting to stop an eating disorder it has acquired a life of its own.

The same can be said for all addictions. I know of almost no

exceptions. In fact, intellectual understanding of the problem only

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adds to the frustration and pain of not being able to stop – even

when you want to. To paraphrase a concept from the text of

Alcoholics Anonymous: “we reach a jumping off point, where we

can no longer live with our addiction or live without it.” Anyone

suffering with an eating disorder has probably experienced this.

Not to be excluded, therapies that focus on “feelings” and

expression of emotions may be helpful to some folks, b u t

appear to have limited value. Not to say they don’t result in

someone feeling better for a period of time, but the

assumption that getting in touch with ones' feelings and

expressing them is the key to resolving an eating disorder is

simply mistaken. Getting in touch with feelings has long been

the Holy Grail among many therapists, counselors, and eating

disorder programs. Feelings have their place in many arenas

such as marital counseling, anger management, anxiety and

mood disorders, etc. However, my experience has been they

have limited value in the recovery world, unless they are in the

service of directing someone to a specific course of action,

which at times can mean simply waiting and exercising restraint.

Taken together, cognitive behavioral therapies, dynamic or

analytic therapies, behavior modification, rational emotive

therapies, pharmacologic therapies, gestalt therapies,

massage therapies, wilderness therapies, homeopathic

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therapies, alternative therapies, and so on – all may be

helpful to varying degrees. However, there is one important

caveat, namely none of these alone provides a definitive

“cure” for an eating disorder or any other addiction that I’m

aware of. Not to beat the proverbial dead horse, but

combinations of many of these techniques may have varying

degrees of benefit - so long as there is no expectation that any

one approach alone represents the “silver bullet” eradicating a

severe eating disorder or related addiction.

Therapy or Therapeutic Setting?

Recovery, to be sure, begins with stopping the addictive

behavior. The next challenge is staying stopped. Doing so often

requires the help of something other than simply good

intentions or resolutions. Few can do this alone. In the eating

disorders world many, if not most, need the collective energy

of a group of other people in a similar dilemma – all who want

to recover. Although a 12-Step or other related support group

may provide this in the long run, often it requires treatment

within a structured and supportive setting to get started.

Powerful and effective as they may be, 12-Step, SMART

Recovery, and similar community based groups offer great

long-term support, but are not intended to replace treatment

when it’s needed.

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A residential or day treatment program can enhance the

chances of getting an initial handle on your eating disorder.

Apart from the benefits of an experienced treatment team, the

appropriate treatment setting is essential for making the

transition from an eating disordered life to a recovery one

possible. The work of creating, facilitating, and managing a

therapeutic community then becomes the primary mission of

any program. Once in place, the work of learning and putting

into practice longer-term recovery skills begins. We often like

to say – “the magic is in the community.” Here’s an excerpt

from the Milestones literature summarizing a mission

statement for our program and facility:

“Milestone's primary purpose is to provide a

comprehensive program to address the

specific needs of individuals suffering with an

eating disorder and the issues often

accompanying them. Providing a safe,

structured, and effective course of treatment,

the facility offers apartment - style residences,

on-site support and a multi - specialty team of

licensed professionals. The program also offers

residential, as well as, day treatment levels of

care. We are a therapeutic community whose

mission is to provide a healthy, safe, and more

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sustainable lifestyle. Many refer to this as a

recovery lifestyle. The program follows a

"blended" approach to treatment - addressing

both the addictive and emotional aspects of an

eating disorder. Residents attend a full schedule

of group and individual activities during the day,

as well as, participate in various support groups

during evenings and weekends. Grocery

shopping, meal preparation, and "real world"

experiences are an integral part of the

program.” [*]

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The Secret to Recovery

Here’s a brief story from a few years ago. Ok, a couple of decades

ago. Anyway, I was a student intern at a fairly renowned

psychiatric hospital and the chief of the psychiatry division, who

appeared to be a rather charismatic and bright fellow, was

taking us on rounds. All of a sudden, out of nowhere, comes

this raging patient who parks his face right in front of the chief’s.

He starts shouting, “how come you won’t tell me the secret?

How come you told John and he’s better now and getting out?

How come you won’t let me know the secret? What’s the

secret to getting better? What’s the secret, tell me.”

Here’s a little background on myself at this point to put this

in perspective. First off, since childhood I always had the

impression I would be “told more about something” or let in

on “the family secret” when I was older. You know the drill.

So, my immediate flashback had to do with the notion that

there was always some secret, some magical answer, drug,

formula, whatever, that would be revealed to me “one day.”

Then, when you become an accountant they bring you into a

room full of accountants and tell you the accountant secret, or

you finish law school and they tell you about the secret

handshake, or you pass your flight test and they tell you the

secret pilot code. Got it? Ok, back to the story.

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Now the chief of psychiatry, without moving so much as a

muscle or batting an eye asks the patient, “So you want to

know the secret, the secret to mental health, the secret to

getting better?” Meanwhile we interns are soiling our

underwear about now. “Yes”, screams the patient, “tell me, tell

me.” Without hesitation, the chief replies, “ok, you want to

know the truth, the secret?” Again, “yes, tell me, please tell

me the secret.” The chief looks directly in his eyes and says -

“hard work.”

To me this was so profound. Why? Because like most of us who

are predisposed to some form of an addiction or compulsive

behavior somehow believe there is a quick fix, answer,

remedy, solution to what ails us. Maybe we think it will be this

new drug, a new diet, this new relationship, a new therapist, and

on and on we go. It wasn’t until several years later that I came

to realize just how right this teacher was. Fact is he was talking

to all of us. If you really want to now the secret and you’re

ready to learn the truth, then be prepared to do the work.

As the saying goes, “faith moves mountains, but be sure and

bring a shovel.”

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Living in the Solution: The Hard Work

Rather than a specific therapy, there is a philosophy that appears

to hold the key to binding all this treatment and recovery stuff

together. Interestingly enough, an anthropologist named David

Reynolds introduced me to this “philosophy” several years ago. Dr.

Reynolds, who last I heard lives in Hawaii and holds a faculty

position at UCLA’s medical school, wrote a book in 1984 with the

title Constructive Living. The good professor chronicled specific

psychiatric approaches taught in Japan referred to as “Morita

Therapy”. He then took these concepts along with another

approach, “Naikan Therapy,” interpreted and summarized their

essence for his book. Having been exposed to what Reynolds refers

to as Constructive Living and putting some of these principles into

practice; it’s become an integral part of the program philosophy at

Milestones. In fact, I have remained both teacher and student with

respect to most of the concepts suggested by this lifestyle. Over

the years I’ve come to recognize all the parallels between a 12-Step

program and a Constructive Living one. I encourage you to keep

an open mind and give careful consideration to what follows. It is

intended only as a brief and simple description of what this

program entails.

*Morita therapy is credited to Japanese Psychiatrist, Dr. Morita

and is the principle impetus for Constructive Living therapy. Naikan

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therapies are attributed to another Japanese physician. It centers

on the practice of a specific focus for meditation and reflection. It

is akin to the concepts of “mindfulness” and gratitude – both

corresponding elements in a 12-Step philosophy. A more detailed

explanation of these techniques can be found in the Constructive

Living text referred to earlier.

Principles of Constructive Living

There are a few basic elements that deserve mention before we

proceed with the “laws of human behavior” about to be outlined.

Many of these fly in the face of what most of us mental health

professionals were taught – at least as it applies to psychotherapy.

I want to add a little disclaimer here and propose a couple of ideas

to consider regarding this Constructive Living (CL) approach.

- The CL approach is not psychotherapy

- CL is basically a form of discipline

- Progress is better measured by behaviors rather than feelings

- Feelings usually follow behavior

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At first glance these concepts may seem simple enough. However,

there is more to this stuff than meets the eye. There seems to be

an implied assumption in the world of mental health treatment

that goes something like this: if we can change how someone feels,

or if we can change what thoughts they have, then we can get

someone to change what they’re doing. I suspect most of us hold

onto the belief that goes something like this - if a therapist or

someone I looked to for help could fix how I feel, then maybe I

would be able to _. You fill in the blank. Try this one on for

size: “If or when you can help me feel better about my body I will

buy shorts and exercise.” “When I don’t feel so big I’ll let myself

eat.” "When I’m not so nervous, I’ll speak in front of the class and

be able to do the presentation.” “When I get [aka feel] motivated,

I’ll study.” No doubt we can make an endless list of “when I feel, I

will.” Experience has shown repeatedly when we put a “state of

mind” as a condition for doing something we’re likely to be stuck

in the problem. Conversely, when we develop the discipline of

doing what needs doing despite the feelings or intrusive thoughts

we are moving toward the solution. Let’s take a few minutes and

look at the basic principles of this philosophy and explore it. I’ve

taken the liberty of paraphrasing some of the CL principles David

Reynolds talks about in his text. They are:

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- Feelings are not directly controllable by self will

- Feelings need to be recognized and accepted “as is”

- Every feeling, no matter how unpleasant, has a purpose

- Feelings fade over time, unless re-stimulated

- Feelings [and thoughts] can be indirectly influenced by behavior

- We are responsible for what we do no matter how

we feel

If you really consider these, they tend to appeal to our common

sense and really don’t require a degree in rocket science. However,

taking a more detailed view and truly contemplating these you’ll

notice a much more profound meaning. What is being proposed

are a set of what could be called, universal truths about the human

mind and how it operates. It suggests trying to control our feelings

by directing energy into simply “willing” ourselves to feel

something is a wasted exercise. Try sitting down in a chair when

you’re feeling sad and “will” yourself to feel happy for any

extended period of time. Try willing yourself to fall in love with

someone you’re not in love with. Likewise, controlling your

thoughts by imposing self-will is quite limited as well. Ever tell

71

yourself not to think about something? I usually end up obsessing

about something the more I try or am told not think about it. The

“magic sauce” in all this is that our thoughts and emotions can be

indirectly influenced by what we do. In other words, what we do

has the greatest [probable] impact on what we think and feel over

time. The cart is placed before the horse when we get it backwards

by insisting we fix our feelings first. Believing our feelings and

thoughts must be changed before we’re able to change our

behavior can be a very costly mistake.

Once again, eating disorders and addictions are about fixing

feelings. Now we can add another idea, this time regarding the

solution – “recovery is about transcending our need to fix how we

feel and doing the next right thing no matter what we’re feeling.”

This challenges the belief that controlling our feelings and thoughts

is the primary goal of psychotherapy. Instead we’re proposing the

reverse - controlling our actions and letting the feelings and

thoughts take care of themselves. “Doing is believing” as I like to

say.

Feelings and thoughts, as we’re reminded, are never constant.

Much like weather patterns, our emotions and thoughts are always

changing. They come and go. In this sense, nothing stays the same.

Trying to exert control over these is like trying to control the

weather – not possible. Behavior, with very few exceptions is

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within our control. Being consistent with what we do is achievable.

The few exceptions I know of have to do with some physiological

stuff – like holding your breath for five minutes or not shivering in

the cold weather or making yourself fall asleep when you suffer

with insomnia, and so on. It’s a short list.

And for the Perfectionist…

Just a brief note to those who tend to sit on the perfectionist side

of the ED fence – “sometimes the “what needs doing” is about

“what needs to not be done.” Most of us who suffer with some

form of an addiction or compulsive disorder tend to display the

trait of dichotomous thinking and behavior. In other words, we

tend to be all or none types, thinking and doing in terms of feast or

famine and living in a black and white world with little room for

any shade of gray. This being the case, some will need to use more

restraint in their recovery program, being less perfect with certain

elements and being mindful of not “over-doing”. Others may

benefit by being more vigilant or compulsive with recovery

behavior. As it relates to an eating disorder, this balance will work

best combined with a prescribed food and exercise plan, a

balancing of work and play along with our overall recovery

activities. Given these extremes, we see people who either weigh

and measure their food to the nearest atomic particle, the over-

doers, or skip weighing or measuring entirely and “count” only the

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amount of food they consume when sitting down - as if standing

and eating doesn’t count. Ok, a little extreme, but maybe not.

Finding the middle ground and the right shade of gray is a big part

of the learning curve.

The discipline with this approach rests with the assumption that

most of us know at any given time what needs doing based on our

circumstances at that moment in time and space. I suspect in

“recovery-speak” this translates to “doing the next right thing.”

Again, sounds simple doesn’t it? Unfortunately, simple doesn’t

always equal easy. Sometimes restraint and doing nothing is the

next right thing and other times doing what we need to do despite

our discomfort is called for. We usually know what our truth is, but

that doesn’t mean we have to like it.

Triggers and the Paula Goldberg Theory

“Feelings fade over time unless re-stimulated”

One of the primary laws pertaining to the human memory is that

feelings and memories diminish in intensity and frequency unless

they are re-stimulated. It’s one of the most important principles

within the context of Constructive Living we spoke about earlier. I

thought I would let you in on how I remember this law and how it

can apply to your recovery. And yes, it’s another story from my

very distant past.

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The dateline is eighth grade at Lawrence Junior High School

somewhere in New York. I am about 14 years old and suffer with

what was, at the time, referred to as juvenile onset obesity. In

other words I was a compulsive eater who was twice the size of

what would be considered “normal” for a 14 year old. So now into

the classroom enters Paula Goldberg, a very “hot” looking 14 year

old dressed in a mini skirt and knee high boots. No doubt you get

the picture. Kind of like the scene from the “Go Daddy.Com”

commercial with the supermodel and computer geek in a lip lock.

Fast forward the movie and I began a “diet” of raisins, cottage

cheese, and diet soda for the next several months until I became

this rather good looking, “svelte,” high school freshman. Now,

eventually, I ask Paula out to the junior, then senior prom.

Throughout high school we were, as they say, an item.

Comes time for high school graduation and off to college. Now

we’re both about to go to different colleges. I figure it’s time for

me to “sow some wild seeds” and not limit myself to Paula. I figure

it’s time to break up with her. Here’s where it gets a little

interesting. I invite her to meet me at the Town Diner [remember

Harry, this is the same place].

So we sit down at the table and Paula says she wants to tell me

something. I tell her “I have something to tell you too Paula, [big

mistake here] but instead I tell her “you go first Paula.” Paula

proceeds to tell me “Marty, you know I care about you, but I think

74

we should take a break from each other and see other people.”

It felt like a dagger was plunged through my heart. Within an

instant my thoughts were: “How could she do this to me? This is

all a big mistake. Doesn’t she know how much I love her? Why is

she breaking my heart?” Here I was about to be the windshield in

this scenario and I end up being the splattered bug instead of her.

This is not right. This can’t be happening to me.

Now it’s Friday night, in fact it’s every night. I’m listening to all of

“our songs,” staring at all our pictures, her letters and cards,

driving past her house and calling her on the phone and hanging

up, and on and on. Carrying her picture for months and asking

everyone and anyone who knows her for the latest news release. I

see a strange car in her driveway and think it’s half the football

team from high school hanging out in her bedroom.

Anyone care to guess what’s happening every time I stare at her

picture, call and hang up after hearing her voice, search for songs I

associate with our time together? Yep, “feelings fade over time

unless re-stimulated.” Staying stuck is about re-stimulating the

pain by repeating the behaviors over and over again. Likewise, if

we don’t re-stimulate desired and appropriate feelings, our good

feelings and relationships also can suffer. Loving someone will fade

over time unless we repeat loving behaviors over time. Now how

does this apply to an eating disorder?

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Some of the actions that tend to re-stimulate eating disorder

feelings, thoughts, and behaviors need to be addressed.

Sometimes we call these triggers.

Using the bathroom scale is a good example of an avoidable

trigger. Weighing yourself frequently will result in re-stimulating

the obsession with numbers and body image. Other examples can

include isolating from friends, spending too much time alone,

eating binge foods, drinking alcohol, refusing to buy comfortable

fitting clothing, going on strict diets, reading fashion magazines

and comparing yourself to the models. The list is almost endless.

The point is to know the triggers you can avoid or eliminate, and

plan for those that you can’t control without acting on the feelings

and thoughts triggered.

In the end, there are some people with whom we want to re-

stimulate feelings and others we need to let go of. There are some

behaviors we want to avoid and others we want to reinforce. There

are times when we need to remember painful experiences so as to

avoid falling prey to the same problem. When you keep this

concept in mind you are able to guide your actions in the direction

you want your attention to go rather than be a victim of

unintended consequences.

To make the point, here’s a version of a three-chapter book on

relapse and recovery that goes something like this:

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Chapter 1:

I’m walking down the street and I don’t notice the hole in the

sidewalk and I fall in it.

Chapter 2:

I’m walking down the same street the next day and I see the hole

this time, but fall in it anyway.

Chapter 3:

I walk down a different street.

Of course, there are a few of us who’ve been accused of re-writing

this book and adding a 4th chapter in the relapse version.

Chapter 4:

I walk down a different street. I don’t see a hole, so I start digging

one.

Let’s leave Chapter 4 for another time. Hopefully you get the point.

There is an old adage that if we don’t remember our history then

we are doomed to repeat it. The "Paula Goldberg” rule is

remembering history and knowing when to re-stimulate stuff that

serves our recovery and let go of the garbage that tends to drag us

back into the abyss of addiction and despair. Farewell Paula.

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So What? Now What?

“Move a muscle, change a thought”

So, if an inability to get in touch with your true feelings and freely

expressing them isn’t the root of the problem and repressed

memories aren't it either, just what then is the problem? So glad

you asked. The true nature of the problem, especially with respect

to addictions has to do with almost total self-absorption and self-

consciousness. If you think about it, no pun intended, most of our

struggles have to do with repetitive and obsessive self-centered

thoughts. This self-centered focus is referred to throughout 12-

Step literature as a root cause of our suffering. Getting “outside

our own heads” by changing our behavior rather than obsessing

via “re-cycle-analysis” of past events and over thinking about our

feelings has its rewards. I’ve heard it said: “I may not be much, but

I’m all I think about.”

Just to recap, psychotherapies began with the notion of unveiling

and coming to terms with repressed memories and feelings. Later

schools of thought began to incorporate concepts such as

“cognitive restructuring” or retraining the way in which someone

sees things or what they may tell themselves. Others placed

emphasis on “getting in touch with feelings” and expressing

emotions as they reach a level of awareness. Kind of, “if it feels

good do it” or “letting people know how you feel.” To be fair, most

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professionals do suggest a measure of caution and social judgment

instead of “letting it all out.” However, I believe those approaches

that emphasize feelings at the expense of accountability hold

limited value in the recovery process.

Even if we can’t stay out of our own way with our obsessive

thoughts about our feelings or how we see ourselves, we can still

do the dishes, prepare the meal, listen to a friend’s problem, take

out the garbage, and so on. Chances are when we engage in doing

what’s in front of us that needs doing, we may briefly get outside

ourselves. Even if we don’t, we still have clean dishes and are rid

of the garbage in the kitchen.

By concentrating on what we need to do and engaging with right

behavior, we begin to have experiences, perhaps glimpses in the

beginning, of getting a respite from our obsessive thoughts. The

end game of a Constructive Living approach is the same as it is with

a 12-Step program – to gain freedom from our habitual patterns of

self-destructive behaviors and reclaim our lives.

In the service of trying to simplify the differences between the

most widely employed therapies today, I would refer you to the

illustration on Table 3.1. Each string represents the sequence of

what needs to happen first and what follows. The last chain with

behavior taking the lead is, in our experience, the most effective.

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TABLE 3.1 – Behavior First

FEELINGS THOUGHTS BEHAVIOR CHANGE

THOUGHTS FEELINGS BEHAVIOR CHANGE

BEHAVIOR CHANGE THOUGHTS/FEELINGS CHANGE*

* CL / Milestones Approach In Other Words -”Easy Does i t…. Bu t Do it”

Have you ever felt tired and irritable and had the thoughts, “going

to school, or work, or a meeting or exercising won’t do any good,”

and ended up doing it anyway? Did your thoughts and feelings

change after? Did you regret having done the work or expending

the effort? Most people don’t complain after they’ve exercised or

finished their homework or finished their degree.

What is being suggested is simply that, although not a guarantee,

there is a good chance doing what needs doing will result in

changing your thoughts and feelings in a positive direction. Some

CL sayings go along the lines of: “If you want to feel healthy, do

healthy things.” “If you want to experience courage, you need to

do courageous things.” “If you want to experience recovery, you

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need to do recovery.” By doing so, your perceptions and thoughts

are likely to be reshaped and indirectly influenced by your actions.

You can again accuse me of butchering another famous quote by

restating it as follows: “I think I am, therefore I am” might be better

stated as “I do, therefore I am” – from that perspective, we tend

to be defined by what we do and not so much by what we say or

feel. Another cliché popular within recovery circles is “we are

judged not so much by our intentions as by our actions.” I know

very few people who get in trouble for what they think or feel, but

plenty who get into issues for what they do. Conversely, proper

action can produce amazingly good results in spite of feeling and

thinking negatively. More than likely the negativity will change

over time if the behavior is positive.

Being realistic about this “just do it” discipline is important. Doing

what needs doing does not always guarantee feeling good or

getting rewarded in accord with your expectations. Here’s a case

in point. I remember trying to put these concepts into practice

some time ago and came home one day to find a bunch of dishes

in the sink that my wife had yet to clean. Ok, I’m [feeling] resentful

that I’ve worked all day and here are dirty dishes that need to be

washed and [I think] my wife is supposed to wash the dishes. Alas,

I am now Mr. CL and will put on my CL outfit and wash the dishes

despite feeling crappy and resentful. Now that I’ve done the dishes

I am expecting my wife to be so overcome with gratitude that she’ll

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shower me with love and affection. Not happening. What I am

guaranteed by doing the dishes is clean dishes.

Perhaps a seemingly silly example, fact is you can control what you

do and maybe influence how you then feel and think. However,

you have little control over the rest of the universe. The purpose

of developing the discipline, or habit if you prefer, of doing what

needs doing as each situation presents itself, is not meant to

always be directed at fixing a feeling. Instead, it is intended to build

a manner of living that is commensurate with recovery and, as

such, offers the most possibilities of minimizing self-inflicted

problems and increasing the quality of daily living. It promises not

to always be a means of feeling well, but instead a means of

learning to do well. Obviously, doing well eventually leads to a

much better batting average of positive thoughts, feelings, and

experiences – especially when you’re able to deviate from an

obsessive focus on yourself in the process.

The following is an excerpt from an earlier article I wrote to

summarize some of the ideas we’ve been talking about here.

Forgive me if some of what you are about to read seems repetitive.

“Much energy is expended in the service of helping people here

explore the full texture of their emotions and beliefs.

Acknowledging our feelings and our thoughts are important.

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Whether expressed or restrained, both need to be recognized and

accepted rather than denied. In fact, when our feelings and beliefs

are pushed aside and not acknowledged we may be prone to taking

actions that are not always in our best interests. The problem arises

when one believes it necessary to understand the cause of our

feelings as a prerequisite for being able to change. Knowing the

why of our feelings is not as important as knowing what it is we

need to do in response to what’s happening in a given moment. I

need not know why I’m nervous in order to walk in front of the

group and give my presentation. I don’t need to understand why

I’m feeling shy around this person in order to initiate a conversation

or ask them out for dinner. Feeling angry, I can still make the bed

and clean my bedroom. Being afraid to fly need not stop me from

buying a plane ticket and visiting my friends. Presentations are

given, social engagements are made, rooms are cleaned, and trips

are taken despite the feelings and thoughts. Doing what needs

doing does not guarantee to “fix our feelings”. It does guarantee

we get done what we need to do without being debilitated or

controlled by our emotions and thoughts. The payoff, if you will, is

huge.

Consistently practicing this discipline diminishes our fear of

experiencing all the emotions and thoughts we’re capable of

having. In other words, we need not avoid our feelings, but can

acknowledge them, accept them, and not have to be ruled by them.

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A way to view all this is to realize we can develop control over our

behavior and not be limited by our fears, emotions, and obsessive

thoughts. Most importantly, we can eliminate the need to self-

medicate feelings as we come to accept them rather than insist

they be changed because they are unacceptable to us. We begin to

realize our feelings and thoughts will not destroy us. Our feelings

will take care of themselves over time if we no longer allow them

to govern all our actions. Progress is best measured in terms of how

we’re doing rather than how we’re feeling over any given period of

time.”

Control Issues

“God grant me the serenity to accept the things I cannot change,

the courage to change the things I can, and the wisdom to know

the difference.”

Of course the catch phrase is the “wisdom to know the difference”

part. Truth be told that can be a sticking point for many of us.

Knowing when to “let go” and when to “try, try again” takes a little

self-honesty and humility. Perhaps a beginning principle here

might be admitting our limitations. It’s human nature to want or

demand we be able to control stuff. The problem arises when we

insist on controlling what is either uncontrollable or directly

clashes with the control needs of someone or something else.

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Controlling your weight by starving yourself puts you in conflict

with your body’s need to control its' health. Your body doesn’t

sympathize with your cosmetic or body image concerns. Typically,

what starts out as you controlling something like food, drugs,

weight, other people’s feelings or behavior, and so on ends up with

“it” controlling you. An integral piece of the ABA text* suggests

most people who suffer with anorexia, bulimia, or a related eating

disorder harbor intense issues with control and trust. It would

seem the focus on control eventually works its way down to a

reliance on self-medicating with food or starvation. Trust becomes

a matter of not even being able to trust oneself, let alone anyone

or anything else.

If you were to look closely at those having the most success with

recovery you’ll likely see they’ve found a way to let go of control

when appropriate and to trust something or someone other than

their “self-will”. It’s been said addictions are “diseases of

perception” and in no other instance have I found that more to be

the case as with an eating disorder. It’s helpful to remind ourselves

where our “best thinking” has taken us.

Proper use of control, namely taking “right actions” and following

a set of prescribed recovery behaviors – treatment that includes a

food and exercise plan, proper rest, and developing your own

sense of spirituality - is within your control. Trying to constantly

control what you feel or think is exhausting and really doesn’t work

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for very long. Furthermore, most of us have an overwhelming

tendency to “over think” and “under do”. The formula usually

comes down to “over analysis leads to paralysis.” I can assure you

no one has recovered from any addiction or eating disorder

without changing the addictive behavior first. Control what you do

and waste as little energy as possible trying to control everything

and everyone else.

Last, but not least, keep in mind the notion of middle ground and

how it applies to the need for some of us to refrain from over-doing

and perfectionism. There is both the need to act despite our

feelings, as well as, the need to employ restraint and not do at

times. Being honest with yourself will go a long way to know what

needs doing in the service of your recovery and not your disease.

********** The Foundation of Recovery – S.E.R.F.

“Read something to someone and they’ll likely forget it, show

something to them and they may remember it, have someone

experience it and they will come to understand it.” – Buddhist

Proverb

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With few exceptions, the human mind will retain a very limited

amount of information unless there is some emotion or experience

attached with it. As it applies to eating disorders, having

experiences with new behaviors around eating, as well as,

experiencing self-care serves us better than intellectual

knowledge. There’s no shortage of dietitians, therapists,

physicians, and such who come to us looking for help with an

eating disorder. Knowing and doing are two entirely different

things. Once again, doing, becomes understanding while

intellectual knowledge alone is just that, knowledge without

benefit.

Now we come to the use of slogans and acronyms that are helpful

to us mortals and remind us of the basics of recovery. I’ll spare the

reader most of these, but tell you one we’ve come up with at

Milestones. It’s an acronym representing the four essential parts

of recovery from an eating disorder namely, spirituality, exercise,

rest, and a food plan - S.E.R.F.

Some time ago I put together a brief article outlining what I believe

to be among the most important ingredients in a long-term

recovery recipe. What follows is an excerpt of the article I

published that also appears on the Milestones Website.

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“There are a couple of assumptions I have regarding the basic

building blocks necessary to build a solid foundation in recovery.

Let me be candid again and put out there one of the more

important ones begins with a total commitment to being consistent

with what we do on a daily basis. This means no matter what we

are feeling, what “tricks” our minds play on us, or what life

surprises us with, we still can control our behavior and be

consistent with what we do despite this. The “first things first”

slogan suggests self-care as a priority. To do otherwise leaves us in

no condition to take care of anything or anyone else. “Placing your

oxygen mask on first before helping the person next to you” is not

just sound advice in the air.

From this standpoint, maintaining a prescribed food plan,

adherence to a moderate schedule of exercise, finding and

maintaining a healthy balance between work, rest, and play, and

cultivating your own brand of a spiritual connection are the basics

– in other words the building blocks in recovery are S.E.R.F.

Now for the tough part that separates a recovery program from a

“diet program” disguised as recovery. Like most addictions and

illnesses that center on our need for CONTROL, all eating disorders

have in common the obsessive focus on the goal of total control of,

in this case, eating, body weight and body image. Letting go of

control from a recovery standpoint is not about “giving up” but

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rather following a prescribed program (as noted above) and letting

go of the outcome – namely not making changes in response to

feelings, fears, or temporary changes in our bodies. Allowing

someone other than us, at least in the beginning, direct our food

and exercise plans is a far more objective and ultimately successful

means of finding a solution to the mental tyranny of trying to do it

alone. To be sure, it takes a quantum leap of faith and courage to

“turn over” control to someone other than yourself. In the end,

sponsorship in an appropriate support group such as OA or ABA,

making good use of a trusted and experienced professional, and

cultivating a belief in your own understanding of a higher power

will put you on the path to reclaiming your life”.

Marty Lerner, Ph.D. I t’ s A ll Ab out th e Fo od …I sn ’t i t?

A food plan is not meant to be a “diet” in the traditional sense of

the word. It is better viewed as akin to comfortable clothing rather

than a straightjacket. It may change and be adjusted over time and

is not a “quick fix” or the be all and end all to treating an eating

disorder. However, it is an integral piece of the recovery puzzle.

Although the term abstinence refers to the cessation of eating

disordered behaviors, whether binge eating, restricting, purging,

and so on, it also can refer to the specific boundaries regarding

properties of foods [types and amounts] within the plan. In

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essence, an “abstinent food plan” is one that suggests eliminating

junk foods, as well as, accounting for portions.

At Milestones abstinence refers to “clean” eating by keeping sugar

derivatives* to no more than the fifth ingredient in any food

product, avoiding most refined flour products, and steering clear

of highly processed junk foods, as well as, being mindful of portion

sizes. With regard to volume, when all is said and done, eating

disorders carry with them a tendency to either over or under

estimate amounts of food eaten or suggested as part of a meal

plan, hence, the recommendation to weigh and measure portions

as part of the experience here. Doing so can be reassuring to the

person fearful of eating “too much” and helpful to those needing

a “reality check” on the volume / amount of food on their plan. It

is intended as a teaching tool and to not “morph” into another

compulsive behavior like calorie counting. Weighing a portion of

chicken or tofu should not be performed as if calculating the

atomic weight of a protein molecule. Likewise, “tossing” an entire

package of cheese on a food scale and rounding off to the nearest

pound, then placing it on your plate is also not in the spirit of

measuring a portion. Once again we need to recognize some need

to be a little more compulsive, while others need to lighten up a

little bit. Feast or Famine, Black or White, Pass or Fail, All or None

– we must find a balance in the middle with our food relationships.

In fact, our approach to eating is probably a metaphor for our

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overall approach to living. Working with an experienced dietitian

and crafting an abstinent food plan that evolves into an

individualized plan over time, is key to finding this middle ground.

Within a given set of guidelines there is room for individualized

plans and differences. One size does not fit all with abstinent food

plans. People will vary with reference to food preferences and the

amounts needed to meet their nutritional needs. It is similar to

what needs doing with exercise plans.

*Sugar derivatives refer to table sugar, corn syrup, dextrose, and

any number of processed products that are chemically equivalent

to sugar and its effect on the body.

To W ei gh or Not to W eigh , T h at i s th e Q u esti on…

Perhaps a somewhat debatable issue is whether we should weigh

ourselves during the course of treatment, as well as,“ever after.”

My vote is a resounding no. The bathroom scale has either been a

source of despair or used as an “addictive tool”, dictating whether

one feels good or bad. Worse yet, it usually progresses to whether

one is good or bad. Perhaps it's better to have a trusted

professional or sponsor, at least during the initial phases of

recovery, monitor our weight for us. Taking a “blind weight” can

help break the vicious cycle of compulsive weighing. Some have

taken the opposite tack and historically avoided the scale

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altogether, although perhaps initially for the wrong reasons, such

as denial. I would still encourage people to refrain from “scale

dependency.”

Better to concentrate on following a reasonable food plan and

practicing the S.E.R.F. formula as a measure of progress, rather

than the number showing up on a bathroom scale. The reason is

simple – the body will take care of itself if we are treating it

appropriately. Cosmetic concerns aside for the moment, the body

will react by finding an appropriate “set point” over time. The set

point may reflect either an increase or decrease in body mass

depending on what “the body needs.” It may also remain static if

the BMI is not a primary symptom of the eating disorder. I would

remind the reader, not all binge eaters are overweight and not all

those suffering with Bulimia are significantly above or below a

reasonable set point. However, if binge eating or restricting has led

to the “symptom” of being over or under a healthy body weight,

then following a reasonable food plan will “right the ship” and

bring the body into balance by restoring a reasonable body mass.

The gap between what is a healthy set point and what ones’

perception of what “looks good” may be a matter of a body image

issue and not a betrayal of your body. The cosmetic norms have

changed as frequently as yesterday and today’s fashion trends,

while the biological norms have not really changed in the past

several thousand years. So, the effort needs to be placed with

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“SERF” and not with manipulating the body to reflect a certain

number or conform to the body image du jour. The “trust” and

“control” issues we spoke about before have to do with trusting

your body’s response to a healthy food and exercise plan and

letting go of trying to control your body’s set point at any cost.

The measuring aspect of recovery as it relates to the food plan is

to weigh and measure our food and not our bodies. Doing so

avoids the tendency to over or under do what’s called for on our

food plan and serves as a teaching tool. It is not intended to

aggravate our compulsive nature, but rather to focus on following

a part of our recovery plan. Whether one continues to do so after

a few weeks or months of recovery becomes an individual choice.

Perhaps the same can be said for being weighed periodically by

yourself or someone else. If the benefits [excuse the pun]

outweigh the negative effects, fine. For most people, relying on

other measures of what’s happening with our bodies such as how

our clothes are fitting, etc. are enough.

Measuring Recovery – How am I Doing?

This is a really short topic. I would encourage anyone with an

eating disorder, or any addiction for that matter, to measure

progress in terms of how one is doing rather than how one may be

feeling at a given time. Quite frequently, we may be feeling bad

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while doing very well and vice versa. Eventually our feelings “catch

up” to our actions over time. This “double edged sword” can cut

both ways. Best to place your bet on doing well and chance that

the feelings will soon follow.

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Chapter 4: Maintaining your Recovery

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S.E.R.F. Lessons

Let’s see how many metaphors we can come up with for the SERF

stuff. “Stay close on your SERF board or you might drown.” Ok, ok,

how about – “The key to SERF-ing is all about balance” – I like that

one. I’m done. Thanks for indulging me.

Spirituality – G i ve me an “ S”

A quick disclaimer, I am no guru or authority on the subject

of spirituality. In the context of eating disorder recovery I would

suggest spirituality is, however, an integral part of ongoing

recovery. Defining spirituality is, at best, ambiguous. That may

be a good thing since there are no rules or religious dogma

attached to its practice. It affords anyone and everyone an

opportunity to participate. So let me attempt to bring together

two concepts that permeate the 12-step addiction recovery

literature – spirituality and powerlessness.

First, allow me to quote from Elisa Goldberg’s workbook used as

a text for her course on Spirituality in Behavioral Health Care

Settings [Drexel University -October, 2013].

“Spirituality is an essential element of human experience. It

represents the part of us that searches for meaning, seeks out

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transcendent experiences, and recognizes that a force exists

beyond the material world. Spirituality encourages hope and

purpose. It can foster positive emotions, coping skills, and

recovery in the face of behavioral health challenges. Although

many important spiritual resources come from religious

practices, spirituality and religion are not the same. Research

has shown a multitude of connections between having faith and

living well with behavioral health challenges, yet most

professionals have little training in the area of spirituality.”

Although there is probably more confusion about the meaning

of “powerless” than just about any other term in the addiction

literature, it really is quite simple. “Powerless” refers to the

addict’s, in this case someone with an eating disorder, being

unable to stop and stay stopped on one’s own willpower. Let

me run that by again. Being powerless means, despite endless

attempts to control your ED on your own, the result is usually

a brief period of remission followed by relapse back to the ED.

The suggestion implied with this concept is to begin looking

for a “power greater than yourself.” Given the track record

of countless attempts to do it on your own this might not be

such a bad idea. This leads us to a discussion and perhaps a

conceptual understanding of spirituality.

Ok, what’s this “higher power” thing about? The ambiguous

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answer is, whatever you deem it to be as long as it is a

“power source greater than yourself.” Regardless of prior

experiences with religious organizations, spirituality begins

with a sense of humility and an awareness of the need to rely

on something or someone other than simply ones’ self. It may

initially involve a reliance on a group of people like a support

group, a 12-Step program, a community of peers at a treatment

center, a group of professionals, really just about anything

other than just you alone. Of course, it may be something

not human at all, such as a universal energy, or of course, a God

of our own understanding.

The point is spirituality has to do with cultivating and developing

a relationship that involves a healthy dependency on a higher

power. It likely necessitates a daily practice reinforcing that

belief with a set of individualized behaviors that are in sync

with your concept of spirituality. It may or may not incorporate

any religious practices or prior beliefs. It belongs to you and

you alone. You define it and you use it as such.

The important part of this letter S in SERF is that it is practiced

on a daily basis. The doing part may include attending

relevant 12 step or other support groups, reading literature

relevant to your flavor of spirituality and values, helping

others, prayer and/or meditation, yoga, or anything that

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furthers your reliance/connection with that “power source.”

For what it may be worth, spirituality fosters the belief that

together with that source you can do for yourself what you

might not be able to do alone. How it works for you will depend

on how you proceed with the rest of the steps in a 12-Step

oriented recovery program or cultivating as an “add-on” to

either existing or a newly acquired set of recovery skills.

An Exercise in Futility? – G i ve me an “E”

As mentioned throughout this text, eating disorders are

characterized by extremes in behaviors, emotions, and

perceptions. A kind of black or white, all or none, approach to

things is certainly part of the problem. So why should exercise be

any different? Coming in basically two flavors – compulsive over-

exercisers and under exercisers. Feast or Famine – where’d I hear

that before? Obviously, some need to increase their activity /

exercise while others need to cut back on the frequency, intensity,

or duration. So here again we need to speak in the language of

moderation and find a middle ground. Exercise in the service of

recovery is not a matter of increasing calorie expenditure, weight

reduction, or building muscle mass per se, although these may or

may not be by products. Exercise is meant to serve both body and

mind in the obtainment and preservation of emotional and

physical health. What a concept!

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Just as an aside, our bodies respond to excessive exercise and

activity [burning too much energy] with fighting for survival. It does

so by conserving energy. Thus, too much exercise and your body’s

metabolism will slow down in an effort to fend off starvation and

tissue loss. In other words, too much exercise and too little food

begins to demand more exercise and less and less food to maintain

continued weight loss or prevent weight gain. Anyone remember

what symptom of addiction this refers to? That’s right – it’s

TOLERANCE. Developing tolerance requires more of the same

behaviors or substances to achieve the same effect. I guess we

could say again this is about “getting caught in your own mouse

trap.” Likewise, the loss of a regular menses signals the body is not

able to withstand the rigors of child bearing while in survival mode

and protects itself by slowing down energy expenditure,

decreasing sex drive, and reverting the body back to an almost pre-

adolescent state.

With the “too little exercise” end of the spectrum, we are caught

up in the spiral of inertia. With an inadequate amount of activity

the body responds in ways that make it ever more difficult to dig

ourselves out of the hole we’ve dug. Our metabolism slows and

our energy levels decrease. We can find ourselves developing

metabolic diseases such as adult onset diabetes [Type II Diabetes]

with increasing insulin resistance. Our overall muscle mass

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decreases and we begin to associate feeling exhausted with

“thinking” we need to feed ourselves.

Moderate exercise is difficult to figure out objectively when in the

midst of an eating disorder. Like hunger perception and body

image, it can be confusing at best. With the amounts of food, we

tend to overestimate and under estimate what’s needed for our

recovery. It’s best to have someone with experience suggest a

reasonable exercise / activity plan along with a food plan in the

beginning. Individual needs will vary in accord with ones’ level of

fitness, their body mass, medical history, and so on. Suffice it to

say, moderate exercise should consider the following factors – for

example, frequency [3-5X weekly], duration [20-60 minutes],

intensity [60-80% of MHR]* may be guidelines.

*Aerobic intensity is usually measured by a formula that considers

someone’s age, max heart rate, etc. For our purposes, intensity can

be equated with being able to carry on a conversation while

exercising without losing your breath.

Rest – The Balance between Work and Play – G i ve me an “ R”

Ok, for some of us it may be “all work and no play” and of course

for others, "all play and no work.” The proper balance between

work and play is an essential piece of the recovery puzzle. I suspect

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the majority of people with an eating disorder fall within both ends

of this continuum at different times during the course of their

disease. Perhaps you’ve gone through a phase of “all in” on the

being productive at work or school bit and “burned the candle at

both ends.” The usual outcome has probably been like some of

our less than stellar relationships and projects – a spectacular

beginning, a somewhat boring middle, and a very dramatic

crashing and burning to the ground ending. Without finding a

balance with the integration of our recovery - meetings, SERF

activities, social relationships, work, school, play time - relapse is

just about certain.

Of course if the pendulum has swung to the all play or doing too

little side, then we can quickly find ourselves making our eating

disorder our “career” and a full-time job at that. Without a balance

and a sense of purpose beyond ourselves, most people with an

eating disorder will be destined to focus on controlling their

feelings with their eating disorder or some other related form of

self-medication.

Activity can also be part of the rest prescription. Misinterpreting

feeling tired and “thinking” we need to rest when, in fact, we’re

mentally stressed out and not physically tired happens all the time.

This is most often the case when our work or schedule involves

more of an emotional investment than a physical one. We

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interpret mental stress as physical stress and think physical

inactivity is in order. Indeed, what needs doing in this instance is

rest that involves activity and movement [aka exercise]. Physical

activity serves to balance emotional stimulation and intellectual

activity balances physical exertion. Physical work necessitates

physical rest while intellectual pursuits require physical activity to

restore balance. All this may sound confusing, but will make sense

after you experience it for a period of time. Whether a person

needs rest by intellectual challenges, physical activity, or play will

vary in accord with their circumstance and daily routines.

Last, but certainly not least, is sleep. Providing yourself with

adequate time to allow for 7-8 hours of sleep nightly is sound

advice. However, it should be mentioned that almost everyone

new in recovery has some difficulty with sleep – usually not able to

fall asleep and/or stay asleep. Sleep is one of the few behaviors we

have limited control over. Over time and with continued recovery

the sleep cycle rights itself and sleep follows a healthy and

predictable rhythm. During the initial part of your recovery you

may benefit from a non-addictive medication. Short of that, I

would suggest providing yourself with ample time to rest and, even

if not sleeping, begin the habit of being consistent with a time for

sleeping. If you are having a problem with sleeping at night, know

this will pass over time. Be careful not to nap or sleep during the

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daytime while your body is making adjustments to a sleep cycle in

sync with recovery.

Food Plans: Food for Thought – Gi ve me an “ F”

Rather than enter the “great food debate” and subject you to more

repetition of what has already been discussed, this section is

relatively short and [there’s that food pun again] sweet. The basics

[cooking pun now] boil down to eliminating sugar, flour, and highly

processed, high-glycemic foods, and controlling the volume of

food on the plan. There is also the suggestion of weighing and

measuring portions to insure accurate portions given the notorious

tendency among us to “distort” amounts.

I want to repeat once again and be perfectly clear the food plan is

not a diet, but a set of boundaries around eating. It is intended to

become a comfortable experience over time and not to function as

a set of handcuffs. The food plan is simply healthy eating,

eliminating junk foods, and insurance against either overeating or

under eating. It is subject to modification and adjustment under

the direction of someone other than you. It has an ability to be

flexible, but not at the expense of certain established boundaries.

Think of it as medication – something you neither prescribe nor

change without talking it over with the person responsible for

prescribing it in the first place.

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At Milestones we don’t place people on either extremely high or

low calorie food plans to achieve rapid weight gain or loss.

Milestones differs from most programs, in so far as, believing

people do better eating an amount of food that will eventually

sustain an estimated weight range or set point. Let’s assume for

the sake of illustration, a person enters treatment with a body

mass equivalent to 200 lbs. with 125 lbs. being an estimate of their

set point. That person would do best eating the equivalent amount

of food commensurate with a 125 lbs. person and not a plan

appropriate for a 90 lb. person. The same would hold true for a 90

lb. individual with a set point of 125 lbs., namely to follow a food

plan meant for a 125 lb. person and not a 200 lbs. individual. There

shouldn’t be a race to lose or gain weight as quickly as possible.

The goal is learning through experience how to live comfortably

within your set point. There is no “finish line.” This should be

happening during and after treatment. You do not want to finish a

program with only the experience of eating like a 200 lb. or 90 lb.

person and suddenly expect to amend your food plan afterwards

to some “maintenance plan.” Over-feeding or under-feeding in a

treatment program tends to reinforce the problem rather than

offer a longer-term solution. As noted earlier, progress is not solely

a matter of a rapid change of the number on the scale.

As a general rule, the food plan considers volume and caloric intake

from the standpoint of the long-term picture. As mentioned

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earlier, the focus needs to be on healthy and appropriate eating

not on rapid changes in body mass. The body will self-correct over

time if it is not treated with extremes or abused. A reasonable food

and exercise plan should be designed with this in mind. The guiding

principle here is to find a means of establishing a long-term

relationship with food and not a dramatic, chaotic one.

*The specifics of a food plan beyond the basics of weighing and

measuring portions and eliminating non-abstinent foods is left to

the program’s dietitian and that person to sort out. Participants

at Milestones are able to choose what their food preferences are,

design, plan, and prepare meals in accord with the food groups

and portions they agree upon with the dietitian. In effect, there is

a balance struck between what is nutritionally needed to

establish and sustain an abstinent food plan and resultant

healthy body. Whether vegan, vegetarian, or some other

variation, there is the ability to find a food plan that will work

within the bounds of recovery.

To be sure, it should be said there exists a small group of people

who come to the point of needing a more aggressive approach to

re-feeding or quick weight reduction. Again, one size does not suit

all. Inpatient and hospital based settings with forced feeding and

strict monitoring, as well as, surgical interventions like gastric

bypass procedures, do have a place in the eating disorder

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treatment world. The program at Milestones is not intended for

such interventions. For those unfortunate enough to have

progressed to that stage, more intrusive measures are necessary.

Indeed, the physical consequences of their illness have become life

threatening and demand a higher level of care than a residential

program can provide. It is a topic for discussion going beyond the

scope of this one.

Basic Tenets of a Recovery Food Plan

Rather than begin with the typical list of menus and foods one

might find in a "diet" book, I thought it best to review some of

the basic principles and operational definitions inherent in a

recovery food plan. I might also add, that these principles

would easily enhance the health and well-being of anyone

following most of these principles and suggestions. Last, but

not least, I would encourage anyone considering following

what we will now term a "clean" or "abstinent" food plan,

consult a registered dietitian familiar with the treatment of

eating disorders, as well as, experienced with addiction.

What follows is a list of the essential elements forming the

foundation (basics) of clean eating for those recovering from an

eating disorder:

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• Highly processed, high-glycemic foods (e.g. sugar/refined

flour/trans fats) should be eliminated or avoided as much

as possible.

• Portions should be weighed and measured so as to avoid

over or under estimating portions. The principle behind

this suggestion is not in the service of reinforcing counting

calories or weight, but rather to eliminate the tendency to

over or under estimate portions.

• Consideration should be given to choosing a variety of

different foods within the bounds of the food plan rather

than getting stuck in rituals or patterns of eating the same

meal repeatedly.

• Eating at regular intervals throughout the day - not

allowing more than 4-6 hours elapse between meals

and/or snacks. The principle here is to not get too hungry.

• With respect to quantity of food (caloric intake) servings of

proteins, complex carbohydrates, and healthy fats should

take into consideration an individual's "set point" or

healthy weight and not reflect rapid changes in body

weight. For example, if an estimate of healthy body weight

is 125 lbs., a food plan should reflect the set point

regardless of whether someone is significantly above or

below a healthy weight.

• Consideration should also be given to activity/exercise

levels that reflect exercise and activity in the service of

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recovery and not in the service of reinforcing eating

disordered behaviors. It is best to have a dietitian or eating

disorder specialist consult on exercise, as well as, food

plans.

• Individual responses and "sensitivities" should be given

consideration with respect to the use of artificial

sweeteners, caffeine containing beverages, and other

foods and beverages that are "triggers" to overeating

and/or producing changes in appetite.

As mentioned, the list is intended to present a broad stroke of the

basics making up a sound and healthy whole food plan. With

respect to the restricting end of the eating disorder spectrum,

experience has demonstrated the need to reinforce adequate

amounts of "clean food" and discourage the tendency to distort a

food plan as a restrictive diet in the service of preventing or

promoting further weight loss. Likewise, the "weighing and

measuring" principle can serve to "reassure" someone they are not

overeating and instead, following a prescribed plan to restore their

body back to health.

Worth mentioning is the notion a food plan is not a diet. For most

of us, a diet represents a temporary restricting of caloric intake via

some combination of foods and/or exercise in order to lose weight.

A food plan, in this case a "clean eating plan" is not meant to be

temporary. It is intended to transform the individual from having

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an addictive relationship with food or dieting to one that is

followed by choice rather than compulsion. In the end, it becomes

a part of recovery that one incorporates into a lifestyle, free from

the tyranny of an eating disorder. The guiding principle of a food

plan is that it fit like a comfortable set of clothing and not be

experienced as a straightjacket. In the last chapter of this book

there are examples of abstinent recipes for your perusal.

Healthy Relationships – T h e 4 A ’s

One of the more challenging aspects of recovery is learning to

navigate through our relationships with family, friends, and co-

workers. One certainty exists for people regarding their ongoing

relationships prior to entering recovery is that; no relationship will

stay the same once they begin recovery. It’s not unusual for people

who care about us to want our eating disorder to end, but aren’t

necessarily prepared for the other changes that usually follow.

These can include becoming more independent and leaving us less

dependent on those who are used to being the decision makers.

Now we demand a “voice” in our relationships and assert

ourselves, and set new boundaries and limits with our significant

others. These may be a few of the more obvious changes, but there

are many subtle “shifts” in our personalities as we emerge from

the ashes of self-hate and isolation. Sometimes in a family or social

network we find our acts of independence can be looked upon as

acts of betrayal. We experience resistance to some of these

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changes as we begin to become more true to ourselves. In effect,

it’s important to anticipate many of our relationships will undergo

“growing pains” with the result being either a permanent parting

of the ways, or a temporary distancing. Often, a coming back

together with a newly defined, healthier relationship will evolve

over time. Although no one is really the ultimate authority on

relationships, here are the essential elements necessary for a

healthy relationship.

The Four A’s of Relationships:

1. ATTRACTION

2. AFFLUENCE

3. AVAILABILITY

4. APPROPRIATENESS

Attraction refers to the physical and personality traits of a person.

What is it that makes us attracted to someone? Character,

personality, appearance and any number of traits can be part of

the equation. Attraction can refer to sexual and non-sexual

relationships. We can be attracted to a friend’s sense of humor, a

teacher’s wisdom, and so forth.

Affluence not only refers to a person’s finances but, more

importantly, their ability to be self-supporting and self-sufficient.

Being affluent in a relationship has to do with wanting to be with

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someone rather than needing to be with someone. It also

represents an ability to think for ones’ self and not be unduly

influenced by the opinions of others.

Appropriateness is characterized by exhibiting acceptable

behaviors in the context of a given situation. What may be

appropriate behavior or language in the locker room may not be

the best for the dinner table, etc. Being appropriate is exercising

sound social judgment.

Availability is about being both physically present, as well as,

emotionally present. Someone who is physically present, but is

emotionally distant is not someone who is available. People who

are active with an addiction, such as an eating disorder tend to be

unavailable. Physical and emotional presence is necessary for

someone to fulfill the criteria of availability

4 A’s – And the Point Is …

When examining our relationships, we might consider whether the

person or persons who are important to us exhibit these 4 A’s. If

not, which are missing? Whether we would like to admit it or not,

most relationships falling short of any one of these are apt to be

problematic. Sometimes we find the problem is with someone in

our family, perhaps a parent. In such instances we are bound to

experience the stress involved with redefining the relationship on

our end. The key to this is accepting the fact that we’re unlikely to

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change others. However, we do have the ability to change

ourselves. This brings us to an important point*.

The point is to not insist on finding someone who makes the grade

or trying to force someone into becoming our version of these

attributes. The real challenge is becoming the 4As.

Relationships in Recovery – “ Rul es of th e Road”

- Water seeks its' own level when it comes to relationships. In

other words, “birds of a feather tend to flock together.” Stick with

the winners in recovery.

- Relationships do not remain the same when one or both people

in a relationship begin recovery. There is a shift in the balance of

power.

- Often acts of [responsible] independence can be perceived as

acts of betrayal when new recovery behaviors begin to emerge.

- As recovery progresses, the tendency is to trade in approval for

respect from others – aka people pleasing decreases and

assertiveness begins to replace it.

- Priorities start to shift in recovery. The need to control others

starts to diminish over time.

- The experience of walking into a room full of people and

wondering “who is going to like me” starts changing to “who do I

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think I might like here?”

- Dropping the idea of needing to be needed in order to feel

secure in a relationship. Allowing others to take responsibility and

make their own mistakes. Staying in a relationship based on choice

rather than need.

- Looking at “your side of the street” rather than habitually

focusing on the other person’s faults or defects. Self-inventory

first.

- Becoming less tolerant of unacceptable behaviors from others

such as abuse or active addictions. Setting boundaries.

- As mentioned, placing your energy with becoming the four A’s

rather than trying to find or control someone to make them into

the four A's.

- Staying “in your own lane.”

There are times when you may find it helpful to look at these

attributes in relation to places and things and not just people in

your life. Take a look at yourself along these lines with a job,

school, your recovery program, your support group, your clothes,

and so on. In each of these you can ask yourself whether you are

attracted to or attractive, as well as, affluent, appropriate, and

available. Very often, you’ll find a direct link between how we’re

behaving with “things” and “places” and our relationships with

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people. Perhaps something to give a little thought to - but then

take action with. The 4 A checklist can give you a general idea of

just how you’re doing "and what still needs doing.”

Compliance vs Acceptance and Surrender

A frequently overlooked phenomenon within the recovering

community, aka 12-step oriented fellowships, is a true

understanding of the subtle difference between being compliant

and truly accepting ones’ “addiction.” A growing number of

professionals, not to mention the recovering community at large,

have long understood addiction is a disease with a common set of

symptoms and characteristics. In most instances these symptoms

are both psychological and physical in nature. Whether we’re

speaking of alcohol, drugs, compulsive gambling, or the different

manifestations of disordered eating [inclusive of compulsive

eating, binge eating disorder, bulimia, or anorexia] they all share a

similar sort of “DNA.” I would refer the reader back to the

professionals charged with defining the symptoms of an addiction

outlined earlier in this book in Chapter 1. Formulated by the

American Psychiatric Association’s Task Force on Addiction, the

consensus stands today as the “Gold Standard” for diagnosing

addiction. In effect, this is one way of restating the difference

between a bad habit and an authentic disease entity.

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Should we look beyond the substance, or for that matter most

compulsive behavior[s], we begin to see what separates those who

enjoy long-term recovery from those who tend to repeatedly

relapse. In other words, exploring the nature of the person and not

simply the nature of the substance or behavior. What follows

comes in large measure from the original works of Harry Tiebout,

M.D., and William Silkworth, M.D. Both men were pioneers in the

field who treated countless numbers of alcoholics and addicts.

Each understood the physical and psychological aspects of

addiction and, in their own way, shed light on what makes

someone suffering with an addiction different from their non-

afflicted peers.

Compliance, Acceptance, Surrender - A Process, Not an Event

Let me begin by clarifying these concepts and elaborating upon the

practical implications of each of these states of mind. Let’s begin

with the notion of compliance. To paraphrase Dr. Tiebout,

compliance refers to an individual “agreeing, going along with, but

in no way implies enthusiastic, wholehearted approval”. Usually

there is a willingness not to argue or resist and although

cooperation exists, it comes with some reservations. In other

words, one is not entirely happy about agreeing or following “the

party line.” The willingness to, let’s say abstain from certain foods,

drink, or substances is somewhat shaky. Suffice it to say it doesn’t

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take much to shift from compliance to relapse. Although the good

doctor speculates this is an “unconscious” phenomenon, I would

disagree. Most people in early recovery have some very conscious

reservations about their “lack of power” [aka lack of control] and

insist on stepping back into the ring after a brief period of

remission. Perhaps we can say compliance is a close cousin to

denial.

Understanding the specific dynamics of acceptance is tantamount

to understanding what separates those with long term recovery

from those who experience only brief periods of recovery.

Continuing with Tiebout’s observations:

“Acceptance appears to be a state of mind in which the individual

accepts rather than rejects or resists: he is able to take things in, to

go along with, to cooperate, to be receptive. He/She is not

argumentative, quarrelsome, irritable or contentious. For the time

being, at any rate, the hostile, negative, aggressive elements are in

abeyance, and we have a much more pleasant human being to deal

with. Acceptance, as a state of mind, has many highly admirable

qualities, as well as, useful ones. Some measure of it is greatly to

be desired. Its’ attainment as an inner state of mind is never easy.”

– Harry M Tiebout, M.D.

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In my experience the transition from compliance to acceptance is

a process rather than an event. As such the period of time from

which a person moves from a compliant stance to an acceptance

state of mind varies greatly. However, I would add to Tiebout’s

thesis, getting from point A to point B is quite similar to what we’ve

come to understand as the stages we all go through upon suffering

a loss. [On Death and Dying: E. Kubler-Ross, 1969]. Letting go of

our primary “reward” or “feel good” thing is no easy task. To be

sure, it is a great loss if you suffer from the disease of addiction.

The experience of transitioning to acceptance, and to that of total

surrender, will encompass the following stages:

DENIAL

ANGER

BARGAINING

DEPRESSION

ACCEPTANCE

As with other losses, one can expect to negotiate these in a

sometimes back and forth pattern, vacillating between stages until

arriving at the final stage of acceptance. It is coming to rest at the

acceptance level that one can understand and experience the act

of surrender. It is here one can sense a lifting of the obsession, no

longer needing to struggle with abstinence, but rather finding a

comfort and rhythm to recovery. Ambivalence about recovery

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dissolves and intervals of serenity and acceptance of “life on life’s

terms” begin to increase.

Over the years Tiebout believed this “conversion experience” is

exemplified by:

• The switch from negative to positive behavior by the act of surrender

• The cessation of defiance and grandiosity: attaining a sense of humility

• Surrender being synonymous with a marked change

in behavior[s].

• Surrender, when maintained, exerts a positive influence on all spheres of ones’ life: physical, emotional, and spiritual.

In effect, getting to this stage in recovery can be viewed as the

precise moment when the tendency toward defiance and ego

driven self-control cease to function effectively. With this, the

individual is totally open to accepting reality. Honesty, open-

mindedness, and willingness replace the negativity and

grandiosity, often the least attractive personality traits common to

most addicts. As the good doctor reminds us, “the act of surrender

is an occasion wherein the individual no longer fights life, but

accepts it.” My suspicion is this process coincides with the

progression of spiritual growth. In effect, there is an acceptance of

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humility and a healthy balance between appropriate self-reliance

and reliance on something other than one’s self [ego].

Marty Lerner, Ph.D. The Transition Home

The most important piece of the treatment experience is the ability

to transfer your experiences to the real world, namely continuing

in recovery after returning home. No one does this perfectly. The

whole idea of recovery is not for it to become your life, but to

enable you to get a life. That being said, your success will greatly

depend on having practiced daily living skills during your time in

treatment. The actual experiences of doing the grocery shopping

and food preparation, attending OA, ABA, and other relevant

groups, following an exercise plan, finding a balance with work,

rest and play, and all the other behaviors associated with

maintaining an eating disorder free life, will enhance your chances

for continued recovery at home. To the degree your last day in a

treatment program is a close fit to your next day home, is the

extent to which you have benefited from your hard work. Once

more, intellectual knowledge of recovery has little to do with the

understanding coming from the doing part.

Continuing your recovery still involves a level of commitment after

you leave the treatment setting. Rather than propose a long

dissertation as to what needs doing for “life after treatment,”

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suffice it to say that long-term recovery is a function of practicing

the S.E.R.F. formula on a consistent basis, as well as, working all

the steps of the 12-Step group you choose to follow. Doing this will

virtually insulate you from relapse if done on a regular basis. Like

taking care of ones’ self with any chronic illness, it will require

some effort and discipline day to day. However, as said before, it

is intended to allow you to “get a life” and not become your life.

Just put the [SERF] eggs in the bowl before the rest of the stuff that

seems to demand “all” your time and attention.

Summary

Before moving on, let’s take a moment and reflect on what’s been

discussed so far. Despite being a little too close to the forest

myself, I’m hopeful by now the reader has an appreciation of both

the nature of the problem and the suggestions for long-term

recovery.

We defined the problem in terms of the physical, emotional

[psychological] and spiritual consequences inherent with an eating

disorder. We looked at what all eating disorders have in common

rather than looking at them as separate entities. We saw the

similarities between an eating disorder and other forms of

dependencies and addictions. Looking forward, we began to better

understand the dynamics of both the disease and treatment.

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I’ve presented the case for looking at an eating disorder, regardless

of subtype, through the addictions prism. Taking an open and

honest look at the traits common to dependency and addiction in

the earlier part of the book, I’ve left it to you to make your own

diagnosis. Going from the problem to the solution, we’ve covered

a few elements common to the treatment of most eating

disorders. We’ve proposed an approach that depends less on

analysis and more on action. Once more a discussion of therapy

has looked at the benefits of purposeful action and the limits of

most talk therapies as it relates to eating disorders. To that end,

there’s been a set of specific “laws of behavior” given to the reader

to test out for themselves. The primary elements of Constructive

Living were considered as parallel to the suggestions common to

all 12-step recovery. They stand as universal principles that appear

simple to understand, but are a challenge to accomplish with

consistency.

Some of what was written outlines a collection of experiences and

opinions evolving from several years in the field. Being on the

treating end of these disorders and listening to the stories of my

patients, has been enlightening to say the least. More importantly

perhaps, wearing the hat of having had a personal relationship

with addiction and recovery has been even more enlightening.

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A significant amount of what’s been presented here also comes

from the scientific literature uncovering some of the mysteries of

the brain. We know more today how addictions and eating

disorders function and what differences exist between people with

and without these disorders. Still, much of what we know today

springs from the courage of so many people overcoming their

“addiction” and sharing their experiences with others, others

looking for what they have found, namely recovery.

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Chapter 5 Continuing Care - After Treatment

"The greatest thing in this world is not so much where we stand, as in what direction we are moving."

- Unknown

"Nobody ever found recovery as a result of

intellectual awakening." - Anonymous

“Religion is for folks that want to avoid going to Hell.

Spirituality is for those of us who’ve already been there” - Unknown

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12 Step Groups and Ongoing Recovery

Given the assumption most eating disorders are inherently

chronic, lifelong illnesses characterized by either short or long-

term periods of remission, we need to consider what affords the

best chance for sustaining recovery. A statement from the

American Society of Addiction Medicine published in 2012 goes on

to say, "Like other chronic diseases, addiction (I will include eating

disorders here) involves cycles of relapse and remission. Without

treatment or engagement in recovery activities, addiction is

progressive and can result in disability or premature death."

To be clear, most physicians, health professionals and the public at

large would have little problem accepting an insulin dependent

(Type 1) diabetic's need to follow a daily routine to fend off the

consequences of their disease. Likewise, looking at any number of

chronic diseases, there seems to be an element of ongoing

treatment or self-care that is necessary to hold the disease in check

or prevent further deterioration. Unfortunately, when it comes to

the disease of addiction, accepting this reality is illusive. In fact,

the "symptom" of denial or rationalization is so prominent as to

convince someone that "coasting on yesterday's treatment" is

sufficient to ward off relapse. Not long after someone is deluded

into believing they are "cured" or no longer need to rely on

anything other than self-will to sustain recovery. More often than

not, experience reveals nothing could be further from the truth.

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Usually the only unknown is when, and not if, relapse will follow.

Although not the only format for ongoing support and recovery,

the basic tenets of 12-Step Programs appear to offer the greatest

opportunity for those suffering with an addictive illness for long-

term, if not lifelong recovery. Although some may benefit from the

professional resources available outside of these groups, all 12-

Step groups provide a "prescription," if you will, for eliminating the

self-destructive substances or behaviors hijacking the addict's life.

Beyond the "1st Step" of these programs, the suggestions outlined

in the remaining 11 steps are identical. The differences among the

programs rest within those attending specific fellowships such as

Overeaters Anonymous, Alcoholics Anonymous, Narcotics

Anonymous, Anorexics and Bulimics Anonymous, Gamblers

Anonymous, and so forth. It might be worth noting, many people

who suffer with an eating disorder also suffer with related

addictions, such as, alcohol dependency, drug addiction,

compulsive gambling, etc. As such, attendance at different

fellowships is not so unusual today, as we begin to recognize

addiction as a disease with similar characteristics having to do with

the nature of the person rather than the properties of a specific

substance or behavior.

Specific to eating disorders, Overeaters Anonymous and Anorexics

and Bulimics Anonymous are among the most attended support

groups offering fellowship and on-going support for those with an

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eating disorder. Each of these programs is self-supporting and

does not charge dues or a fee for membership or attendance at

meetings. Each has literature available to outline the experiences,

suggestions and "steps" that are the foundation of their respective

programs. Each also lists resources and websites that link people

to online meetings, schedules and locations of local meetings, and

a variety of other materials related to eating disorder recovery.

There are several slogans, sayings and "catch phrases" that have

circulated within 12-Step recovery programs. Those encouraging

people to practice H.O.W. – Honesty, Open Mindedness and

Willingness, and to avoid the tendency to prejudge due to –

"contempt prior to investigation" – are essential to those new to a

12-Step Fellowship.

In the end, the purpose of any 12-Step fellowship and program is

not to replace professional treatment when needed, but serve as

a consistent long-term support network. Most members of these

groups find regular attendance at meetings in conjunction with

"working the steps and helping others" as indispensable to their

recovery. If asked, they would likely explain their consistent

participation is not a "sentence," but rather a "reprieve" from the

misery of an eating disorder, albeit "one day at a time."

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Open Letter for Revised Edition of Basic OA Text Revised and published in the forward OA 3rd edition, 2014

In August of 2010 Overeaters Anonymous celebrated its Golden

Anniversary at its world convention in Los Angeles. As someone

who has treated compulsive overeaters for more than three

decades, I was privileged to be an invited guest to join in the

celebration. As a point of reference my professional relationship

with OA dates back to my earlier years in practice, as I began to

refer many of my patients to the local OA groups in my area. Doing

so left me indebted to the courageous members of this fellowship

who taught me so much more about this disease than I could have

ever imagined. Since that time, Overeaters Anonymous has been

of virtually indispensable support for those who have come to our

facility seeking treatment. Here's a little background to shed light

on some of my experiences through the years.

Before delving into my history with OA, I’d like to put forth a brief

editorial comment at the outset. That is, I have long believed

Overeaters Anonymous not only serves as a program of ongoing

recovery for those suffering with compulsive overeating, but also

for those struggling with similar eating disorders. More specifically,

I have continued to witness the success of countless people

working the same 12-Steps, adopted from Alcoholics Anonymous,

in OA. Many of my patients, past and present, suffering with

bulimia, binge eating disorder, and related eating disorders have

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found refuge and recovery at the meetings and among the

fellowship that OA offers. Truth be told, I believe OA holds a place

for anyone wishing to refrain from a compulsive or addictive

relationship with food.

I finished my training as a clinical psychologist in 1979, passed my

boards, and began a practice specializing in the treatment of eating

disorders. As part of my graduate work, I had been engaged with

various research projects examining the regulation of eating and

body weight. You could say I became an expert on what made

laboratory rats and mice overeat and become overweight. You’d

be surprised to learn humans and rodents are quite similar when

it comes to being predisposed to abnormal eating. Anyway, over

the course of the next several years I graduated to treating people

with varying types of eating disorders, most notably compulsive

overeating, bulimia, and what is now termed binge eating disorder.

What I discovered, over time, was simply that weight was but the

symptom, and the disease was really an addictive relationship with

food and/or dieting. I say this because I began to see people at the

university’s clinic who were not overweight, yet clearly ate

compulsively. Most of these compensated for their overeating by

either “making themselves sick” and getting rid of the food, over

exercising, or alternating between periods of copious overeating

followed by restricting, aka dieting. Of course, the majority of folks

coming to our program suffered with varying degrees of obesity,

the symptom most identify with compulsive overeating. Despite

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this, I soon concluded the more appropriate measure of the

problem lies with the physical, emotional, and spiritual

consequences and not the number on a bathroom scale. In effect,

compulsive overeaters had more in common with their alcoholic

and drug addicted brethren than most realized. There was more to

this than a “weight problem.” In fact, today we see any number of

AA and NA members who are also compulsive overeaters, and

attend OA meetings as part of their ongoing recovery programs.

Not so different than the misguided beliefs about alcoholism in

years past. The professional community is currently divided as to

how to view, let alone treat, compulsive overeating and related

eating disorders*. If we distill the basic essence of the division, it

would come down to those who view the compulsive eater as

suffering with a psychiatric illness, coupled with a lack of discipline,

and those who view it as an addictive disease. Historically,

however, there has always been a small group of researchers,

physicians, and healthcare professionals who have held steadfast

to the addiction thesis. I’m pleased to report this minority group of

professionals is multiplying and gaining momentum. Fact is, recent

advances with brain mapping technology, such as MRI imaging,

have clearly identified specific chemical responses in the brain that

differentiate the compulsive overeater from his “non-addict”

peers. The evidence has taken speculation and theory to the level

of scientific fact. Personally, this has only served to validate those

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of us supporting OA through the years – namely compulsive

overeating deserves to be recognized the same way we’ve come

to understand and treat alcoholism and drug addiction.

It’s been my experience that active participation in a 12-Step

program such as OA, is indispensable to the ongoing success of

anyone wishing to recover from compulsive overeating or a similar

eating disorder. Although not intended as a substitute for

professional treatment when called for, OA affords the best

opportunity to gain and keep a foothold in recovery. For purposes

of making this point, I’d like to add a quote from the American

Society of Addiction Medicine as it defines the disease of addiction.

One can substitute the phrase compulsive overeating to clearly see

that the proverbial shoe fits.

“Addiction is a primary, chronic disease of brain reward,

motivation, memory and related circuitry. Dysfunction in these

circuits leads to characteristic biological, psychological, social and

spiritual manifestations. This is reflected in the individual pursuing

reward and/or relief by substance use and other behaviors. The

addiction is characterized by impairment in behavioral control,

craving, inability to consistently abstain, and diminished

recognition of significant problems with one’s behaviors and

interpersonal relationships. Like other chronic diseases, addiction

involves cycles of relapse and remission. Without treatment or

engagement in recovery activities, addiction is progressive and can

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result in disability or premature death.” -American Society of

Addiction Medicine, 2012

Just about anyone who has attended a support group such as OA

for any reasonable period of time will likely hear “their story” told

by another member. The effect of one person’s experiences shared

with a fellow having the same experiences is, to quote a related

program, “unparalleled.” Once the initial layer of the onion is

peeled away, namely the “but I’m different than these people,”

then the stage is set for identification rather than comparison. The

question then becomes, “so what do I have in common with all

these people?” “Maybe I’m not alone or so different.” From that

point forward, the focus begins to center more on the solution –

“what do I need to do to recover?” The “magic” of OA seems to

then become clear - a combination of people having a common

purpose and seeing others working a set of suggested steps,

lending testimony to the promise of recovery.

It is my sincere hope the fellowship will continue to grow and its

members serve as a beacon of light to show the way to those who

have yet to find OA. It’s a spiritual axiom, that a group of people

with a common history and purpose can do as a group what could

not otherwise be achieved by the individual. In that sense, OA

offers what no professional or single person can match – hope by

example. -Marty Lerner, Ph.D. 2014

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S.M.A.R.T - An Alternative or Add-On to 12 Step Organizations? Reprint of a “Self Growth” article written [M. Lerner, Ph.D. 2014]

In the world of addiction treatment there are several choices one

has in the way of utilizing and attending a community based

support group. Should one look more closely at what is offered to

those with an eating disorder the choices are somewhat more

limited, but none-the-less do exist. This article takes a look at two

diverse, yet complimentary approaches, 12 Step oriented

programs and the SMART Recovery program.

A detailed description of both may be beyond the scope of this

article. However, suffice it to say both “philosophies” or “beliefs”

have inherent similarities, as well as, differences. To that end, I

hope to distinguish what each brings to the table that is unique and

what they share in common.

SMART Recovery Basics

Let’s begin with what SMART (SR) stands for, namely Self-

Management and Recovery Training. In a nutshell, SR offers a 4-

Point Program [not to be confused as “steps”] that amount to 1-

Building and Maintaining Motivation, 2- Coping with Urges, 3-

Managing Thoughts, Feelings, and Behaviors, and 4- Living a

Balanced Life. SR can serve as a stand-alone approach or

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compliment another program such as a 12-step group or

professional treatment. SR does not necessarily adhere to the

premise that one need attend meetings as part of a lifelong

process, as there is a beginning, middle and end to treatment for

an addiction. Hence once an “addict” you are not always an addict.

Another, what I believe to be very important distinction, SR is

intended to be open to support any addiction and does not hold

separate groups for compulsive overeaters, alcoholics, drug

addicts, compulsive gamblers, and affected family members.

Virtually anyone with an addictive or compulsive behavior[s] with

a desire for abstinence from these, may benefit from attendance

and are welcomed.

Having the benefit of experiencing both a 12-Step Program for

many years and, more recently becoming a trained facilitator for a

SMART Recovery group, I would say SR represents a more updated

approach to addictive problems. Although there are no bona fide

studies to support the efficacy of one support group over another,

there is ample research to support the effectiveness of the “tools”

and techniques taught in the groups. These include motivational

interviewing techniques, cognitive behavioral approaches to

confronting urges and destructive behaviors, and developing

alternate healthy lifestyles to replace addictive and compulsive

behaviors. SR encourages participants to take an active role in the

group process, and unlike the format of a 12-Step meeting, talking

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between group members is encouraged. In effect, each participant

serves as a therapeutic agent in the meeting. Last, but certainly not

least, much of the literature offered by SR incorporates a “how to”

compilation of the tools and techniques discussed at the meetings.

Rather than “steps” to be completed, the SR Handbook, as an

example, provides an ample supply of worksheets and structured

assignments that correlate with the four point program outlined

from the beginning – motivation, coping with urges, managing

emotions, thoughts, behaviors, and lifestyle change. Although not

dissimilar from the 12-step notion of “into action”, SR is a program

of “doing is believing” rather than simply an intellectual exercise.

In passing, it’s worth noting SR holds no requisite that cultivating a

spiritual belief system or reliance on a “Higher Power” is

synonymous with ongoing recovery. SR does not discourage or

encourage individuals from bringing their religious or spiritual

beliefs into their “personal” program of recovery. SR is quick to

point out it is not a spiritual based program and as such, steers

clear of incorporating such principles in their approach to

abstinence.

Comparison with 12-Step Programs

First, I would begin by stating both programs are careful not to

claim superiority with the belief “one size fits all” with respect to

addiction recovery. As such, the “bashing” of one program versus

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the other is discouraged and both programs promote a philosophy

of open mindedness and seeing what works best for anyone

seeking abstinence* from their addictive substance or behavior[s].

*Both programs support abstinence, but SMART does not require

abstinence from "everything," only those substances or activities

that are selected for abstinence by the participant.

While on the topic of similarities, it’s also important to note both

programs encourage the use of medical and relevant professionals

when appropriate, as an integral part the recovery process.

Inherent with that policy is the notion SMART Recovery and 12-

Step programs are there to serve as a support network and not a

substitute for medically necessary treatment when called for.

Indeed, one may argue there is a practical difference between a

support group and a treatment program. For a substance

dependent person medically supervised detoxification may be

indicated as a life-saving procedure. Likewise, for someone in the

grip of an eating disorder, medical stabilization and a structured

setting may be necessary to gain a foothold in the beginning stage

of the recovery journey. Yet for others, the frequently associated

mental health issues, such as depression, may require the use of a

suitable medication, and so on. Although I could go on with a list

of other relevant common denominators, I would suggest

someone approach each with an open mind and experience both

groups a fair number of times, to be in a position to choose which,

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if not both, offer the best opportunity for continued abstinence.

Indeed, some people will choose one program over the other while

still others will see each group as offering something unique and

worthwhile – opting to attend both on an on-going basis.

To someone reading this with no prior experience with a 12-step

program, I would suggest it is, at least for me, difficult to put an

aggregate of experiences into words to adequately describe them.

What I would say, unlike SR meetings, 12-Step groups are intended

primarily for specific addictions and are not one “fellowship” but

many. In other words, alcoholics would attend an AA meeting

[Alcoholics Anonymous], Overeaters go to OA, Anorexics and

Bulimics [ABA], Compulsive Gamblers [GA], and so forth. Although

not a religious program, there is a strong current of encouraging

someone to work toward their own version of “a power greater

than themselves” or a sense of spirituality, without defining what

that should be for the individual. In this sense, the program is not

religious and purposely leaves the concept of a higher power

strictly up to the individual. To be sure, there are members who

have succeeded in these fellowships who are agnostic or atheists,

and there are no “musts” in the program as outlined in their

literature. The [suggested] steps represent a series of actions or a

progressive formula participants are encouraged to complete over

time – with the inherent belief that doing so will not only result in

continued abstinence, but also lead to a more productive and

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satisfactory lifestyle, usually referred to as recovery. Although

much can be said pro or con for 12-step programs, the proliferation

of groups and meetings is enormous, with hundreds of meetings

taking place on a weekly basis in just about every major city here

in the U.S. and throughout the world. Membership in AA alone is

in the several millions and the off spring programs attended by

hundreds of thousands if not millions of others. Perhaps one of the

greatest strengths of 12 step programs is the frequency of

meetings and the fellowship opportunities they provide for people

to find support and some hope with their struggle to free

themselves from the tyranny of their addiction.

As mentioned, I would encourage someone looking to initiate the

recovery process or to add to an existing repertoire of recovery

support, to attend several of these meetings and then decide

which, if not both, prove helpful. To learn more about these

meetings and groups you can go to http://www.smartrecovery.org

as well as, a particular 12-step fellowship site such as

http://www.AA.Org or http://www.aba12steps.org/, etc.

Marty Lerner, PhD CEO, Milestones in Recovery

138

Continuing Care Resources

Just as a point of reference, there are a number of on-

going methods to connect with Milestones’ alumni, as well as

others with similar histories, to help keep your recovery.

There are opportunities to attend twice monthly and monthly

aftercare meetings. These are available in Philadelphia, New

York, and Richmond, VA, as well as, at our offices in South

Florida. An up-to-date list of topics and dates is available on our

website: www.milestonesprogram.org under the News section.

These groups are open to anyone wishing to participate.

There is also an opportunity to access our support groups via

toll-free teleconference sessions*. Beyond these options, there

is an individualized continuing care plan integrated into the

program here at Milestones, and presented to each participant

prior to discharge. This is the case for most other ED programs

as well. For those not having completed treatment at

Milestones, we offer group and message board forums on our

social networking groups at Facebook and Yahoo Groups, which

can be accessed via our website’s home page.

Last, but certainly not least, are groups such as OA (Overeaters

Anonymous), ABA (Anorexics and Bulimics Anonymous), and

a variety of other relevant 12-Step and non-12-Step support

139

groups.These are available throughout the U.S. and

internationally. Both of these organizations list meetings that

can be attended in person and online via the web.

* To participate in the eating disorders support group via teleconference calls, contact us via our website, www.milestonesprogram.org or call our toll free line at 800- 347- 2364 for a schedule of meeting times and the toll free conference number.

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Chapter 6

Additional Information

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Understanding Insurance and the Cost of Treatment

A clear and concise understanding of your insurance benefits and

what will or won’t be covered for an eating disorder [or a related

diagnosis] can be both confusing and overwhelming. As an

example, your insurance may list mental health as a covered

benefit [eating disorders fall within that category], but require you

to be “pre-certified” for a specific treatment [level of care]. In

doing so, the insurance company typically will utilize a set of

criteria to determine if the severity of your eating disorder meets

their criteria for “medical necessity”. As such, it’s possible you may

have the benefit, but are denied access to the program or level of

care you are looking for.

Typically, when someone considers coming to a residential, day

treatment, or intensive outpatient program such as ours, they

participate in a clinical assessment to determine their treatment

needs. Although most insurance benefits include mental health

benefits, including a residential program, a few do not.

However, assuming you do have benefits that include the

continuum of care [residential, partial hospital, and intensive

outpatient options], the provider or program will be better able to

estimate what will or will not be approved based on the findings of

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your clinical interview [assessment]. Often the assessment can be

conducted via a structured phone interview.

As if the above isn’t complicated and confusing enough, there is

also the matter of what your particular insurance policy requires

as a “deductible” and what your “co-pay” would be for particular

services. Usually, these will be a function of whether you are

requesting services from a “network” or “out of network”

provider. Out of network providers [facilities and providers] usually

involve a somewhat greater “out of pocket” expense on your part.

That said, the good news is that after you reach [spend] a specified

amount of your own money, your insurance will typically cover

100% of the remaining costs provided you are “certified” for the

treatment you’re requesting.

By way of example, someone coming to a program or provider

contracted with XYZ insurance, may have a $250 deductible and no

co-pay for residential treatment for an eating disorder. In this

instance, the maximum out of pocket expense or financial

responsibility for that person is limited to $250 – assuming

the insurance company’s medical criteria for that level of care is

met. Likewise, someone who has a different plan may have no

deductible and no co-pay, and hence have no out of pocket

expense. Lastly, someone who is using an out of network benefit

will likely still be covered after their deductible is met,and, in some

instances, have a small daily co-pay during their stay.

143

Given all the above variables and possibilities, it comes down to

finding someone who can verify your benefits and be able to give

you a clear understanding of what to expect. In doing so, it is

important to realize some of the answers to your concerns can only

be estimated and predicted on past experiences with your

insurance company. This is because your insurance company will

not usually commit, in advance, to a specific length of stay at a

given setting or level of care. As such, you will want to know what

contingency plan exists should your insurance company [or your

managed care company] decide you no longer need treatment at

that level of care or program.

In effect, you may want to discuss your “worst case scenario”

before you commit to a treatment program, as well as, what the

most likely scenario will be. Unfortunately, there is typically some

element of uncertainty when dealing with insurance coverage and

treatment. Your job is to minimize this uncertainty, so you can

focus on the task of recovery. Here is where the experience and

integrity of the person reviewing your insurance is so important.

This process begins with a call to the provider or facility admissions

director. Knowing the proper questions to ask is important.

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Here are a few questions to ask…

• Are you in-network with my insurance company? If not, will you accept my out of network benefit?

• What is my out of network benefit and deductible?

• What is my daily co-pay, if any, at your program?

• What is the likely maximum out of pocket expense at your facility for the level of care I need per day? [e.g. residential, day treatment, or intensive outpatient]

• What can I expect my out of pocket expense will be for

the recommended length of stay

• What is the average length of stay at your program?

• Will I receive a bill for treatment after I leave?

• Will I know prior to admission what my insurance will and will not pay for?

• Will you let me know beforehand, if there is any denial of

authorization for treatment, that I will be responsible for later?

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Clean Eating (Abstinent) Suggested Recipes

In order to guide the reader toward the spirit of clean eating and a

healthy food plan, I’ve taken the liberty of assembling a few recipes

for consideration.

Special thanks to our alumni, our own Milestones dietitian, Nikki

Glantz, R.D., and the folks at the Miami Dade group of O.A. for

giving us permission to include some of their “creations.”

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Breakfast Pancakes, Oatmeal, Cottage Cheese

(2 servings)

1 ½ cups rolled oats

3 tbsp. oat bran

1/3 cups cottage cheese

3 egg whites

1 tsp. vanilla [alcohol free]

Mix in blender until smooth, cook “batter” a la pancake in pan

with Pam

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Cold Cereal extraordinary

(1 serving)

1 oz. dry cereal [corn or rice flakes, puffs, etc.]

1 cup yogurt [sugar free]

1 cup peaches [frozen]

sugar substitute [optional]

1 tsp. vanilla [optional and non-alcohol]

Mix all ingredients and place in freezer for 5 minutes…

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Oat Bran, Apple Walnut Porridge

(1 serving)

¼ cup oat bran

½ cup applesauce

2 oz. walnut pieces

1 cup water

1 packet artificial sweetener

ground cinnamon to taste

Bring water to a slow simmer. Add oat bran and cook [stirring]

until thickened - [about 3 minutes]

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“The Doctor’s Opinion” Pancake

(1 serving)

½ cup quick cook [instant] oatmeal

2 eggs / or equivalent egg beaters

2 tbsp. low fat yogurt

1 tbsp. low fat sour cream [optional]

2 tbsp. sugar free maple syrup [optional]

Mix until a batter [using a blender is best], spray Teflon 6” pan

with non- calorie vegetable spray [Pam], and flip over and finish

as a pancake.

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Oat Bran Muffins

(2 servings)

2 eggs

½ cup ricotta cheese [low fat]

1 cup oat bran

2 cups blueberries

1 tsp. agave nectar [or sugar substitute packet]

½ tsp. baking powder

1 tsp. vanilla [alcohol free]

cooking spray

Mix all ingredients and pour into muffin tins. Bake at 350 degrees

for 20 minutes.

Let cool, remove from muffin tins / pan wrap tightly in plastic

wrap and store in fridge or freezer. To reheat, microwave in a

slightly damp paper towel.

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Chicken and White Bean Salad

(2 servings)

6 oz. chicken, chopped

4 oz. cheese, feta crumbled

1 can cannellini beans, canned, drained

1 cup zucchini, diced

1 cup celery, diced

2 cups lettuce, romaine, raddichio, endive

4 tbsp. olive oil

2 tbsp. vinegar, or lemon juice

6 tbsp. orange juice

1 tsp. mustard, prepared brown

1 clove garlic salt and black pepper

Dressing: Peel the garlic clove and smash with side of a chef’s

knife. Use a fork to mash the garlic with ¼ tsp salt in a small bowl,

forming a course paste. Whisk in oil. Add the orange juice,

vinegar, Dijon Mustard and pepper to taste. Whisk until well

blended. Set aside.

Notes: The classic vinaigrette recipe is 3 parts oil to 1 part vinegar. You can decrease oil ratio if you substitute less tart rice vinegar, lemon juice, or a combination of vinegar and orange or grapefruit juice.

You can use any canned white beans such as garbanzo, [cannelloni beans are also known as navy beans].

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Chicken Avocado Layered Salad

(2 servings)

8 oz chicken, cooked

2 cups lettuce, shredded

½ cups sliced radishes

1 stalk celery

1 medium scallions, sliced

8 tbsp. avocados

½ tsp. Worcestershire sauce

3 tsp. vinegar, rice wine, or any kind vinegar

¼ tsp. mustard, dry

4 tbsp. water

1 cup rice, brown, cooked

Salt and pepper to taste

1. In a large bowl, layer ingredients in the following order:

half the lettuce then radishes, then chicken, then celery,

then remaining lettuce, and the scallion.

2. Dressing: Mash avocado in a small bowl. Blend in dry

mustard. Add vinegar, Worcester sauce, and water. Mix

until creamy

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Crab and Avocado Salad

(2 servings)

8 oz crab meat

1 medium tomato, plum, seeded and chopped

½ cup celery, chopped fine

½ small red onion, minced

1 medium avocado, peeled and cubed

2 cups lettuce, boston

2 tsp. lime juice

1 cup amaranth. cooked

Salt and pepper to taste

1. In a medium glass or ceramic bowl, combine the onion,

lime juice, tomato, salt and pepper. Add crab and toss

gently with avocado, lettuce, and celery

2. Serve over cooked amaranth or sprinkled with popped

amaranth.

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Egg and Goat Cheese Frittata

(4 servings)

5 eggs

2 tbsp. milk

1 cup tomatoes

3 oz. cheese, goat crumbled

2 cups frozen broccoli chopped [thawed]

2 cups brown rice, cooked

Salt and pepper to taste

1. Mix eggs and milk in a large bowl. Add crumbled goat

cheese and chopped veggies and cooked rice. Season with

salt and pepper.

2. Spray muffin tin with cooking spray [Pam]. Spoon egg

mixture into muffin tins.

3. Bake at 350 degrees-15 min or until set and lightly

browned

4. Refrigerate until ready to serve-then heat in microwave

30 sec.

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MILESTONES IN RECOVERY located in Cooper City, Florida offers both residential and outpatient treatment for eating disorders. The program at Milestones offers a blended approach to treatment – addressing both the addictive and emotional aspects of an eating disorder. Unlike a traditional inpatient or hospital environment, Milestones affords an opportunity to gain a foothold in recovery in a less restrictive setting, while still providing necessary support and structure. This involves supervised grocery shopping, learning about and preparing meals for oneself, and engaging in both therapeutic and leisure activities outside the confines of a hospital setting. In effect, we offer an opportunity to put into practice, that which is necessary to free someone from their eating disorder.

Do you or someone you love suffer from an eating disorder? Do you have questions? Unsure if treatment is right for you? Call us toll free 800 347.2364

MARTY LERNER, PhD is Executive Director of Milestones in Recovery. A graduate of Nova Southeastern University, Dr. Lerner is a licensed and board certified clinical psychologist who has appeared on numerous national television and radio programs, including: The NPR Report, 20/20, Discovery Health and ABC’s Nightline, as well as, authored several publications related to eating disorders in professional literature, national magazines and newspapers including USA Today, the Wall Street Journal, New York Times, Miami Herald, Orlando and Hollywood Sun Sentinels. An active member of the professional community here in South Florida, Dr. Lerner makes his home in Davie with his wife Michele and daughters Janelle, Danielle and their dog, Reggie.

2525 Embassy Drive, Suite 10 Cooper City, FL 33026

800 347-2364

http://www.milestonesprogram.org

Milestones Nutritional Guidelines Abstinent Food Plan

Revised 1/15

Disclaimer: The information and suggestions in this manual are based on the author’s training and experiences in helping many people in recovery. Please consult your family practice physician and any other medical professionals who understand your individual health situation before beginning this or any other plan of eating. This material is not a substitute for any medication or treatment prescribed by your doctors. Food, medications, allergies, and intolerances are individual and can interact in unpredictable ways. This publication is intended to be helpful and informative. It is not a substitute for professional medical care or personalized professional services. Please use this manual only as a basis for your work with your chosen medical professionals.

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What is a Food Plan? What is a food plan? Why would I need one? Why would I ever want one?

A food plan is a description of the foods you will eat in a specific and planned way: it describes what you will eat, when you will eat, how much of each food you will eat, and when you will stop eating. The foods that you avoid eating are not included on your food plan.

This food plan is designed for people in recovery from “food addiction”, or “compulsive eating”, using the addictive model and a Twelve Step recovery program. It is designed to be used as part of a process with a registered dietitian. Your recovery process is best shared with others who can help you, such as a dietitian/nutritionist, sponsor, support people, and other health care professionals.

To diminish abusive, compulsive behaviors, recovery food plans have these characteristics:

• Remove all foods, which set off or perpetuate inappropriate or self-destructive food behaviors

• Meet the nutrient requirements of the body

• Minimize food cravings

• Provide enough food to feel satiated - not ravenous or overstuffed throughout the day

• Help manage any medical problems

• Be flexible enough to allow participation in normal activities

• Provide adequate time and energy for other lifestyle activities

• Allow space for spiritual pursuits

As you and your nutritionist begin creating an individualized food plan, please remember that no decision is permanent. A food plan must be individualized to your specific situation. Together, adjust your food plan until you find a pattern of eating that works well for you. If your food plan program is stable and comfortable, use the information in this book to broaden your choices.

Please note: If you have any medical condition (diabetes, hypertension, pregnancy, etc.) or if you have anorexia or bulimia, it is not safe for you to try to follow this food plan by yourself. Be certain to get adequate appropriate professional help!

Please do not try to create a food plan on your own. By picking up this booklet, you know that solving this problem by yourself has not worked. Choose one person, like your registered dietitian or other health care professional, to help you make decisions about the content and direction of your food plan. Then commit to follow the food plan for a specified period of time, or until you agree with that one chosen person to change it.

The primary purpose of the food plan is to provide a structure for abstinent eating. Abstinence means freedom from self-abuse and obsession with food. It means you no longer use food to manage feelings; it means you no longer starve, restrict, overeat, binge, purge, or do other harmful things to yourself with food. It means you have enough nutrient- rich foods to maintain your body at a healthy normal weight. It means you have the flexibility to live a joyful, useful life without struggling around food. The food plan begins the process of abstinence by removing all binge and trigger foods and by providing balanced, appropriately sized meals and snacks. Trigger foods are foods that set off your cravings or your desire to use food inappropriately. Trigger foods vary from individual to individual. Some foods may trigger you on a physical level. Others may need to be removed because of what they symbolize - what they have meant to you in the past - as a comfort food or as a way to manage feelings or situations.

Binge foods are those you choose first and use the most often in the process of eating abusively. Any food you used to stuff yourself, to avoid painful life events, to medicate feelings, or to punish or to nurture yourself may need to be removed temporarily or permanently.

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Foods that are similar to your binge foods - that look, smell, or tastes like them - or that are made from the same physical ingredients - also need to be removed. Dietetic “desserts” may set off your desire to overeat because of their similarity to foods you have eaten abusively in the past. Remove any and all foods that consistently set off your need to eat inappropriately.

Foods are divided into categories based on their nutrient content. What follows are lists of the foods and food categories with comments and suggestions for each.

Using these food lists, a food plan will be created by your dietitian listing the servings of each food at each time of day. You may choose any food within a category; do not replace foods in one category with those from another. Do not combine meals or snacks, move foods from one meal to another, or skip foods or meals. If the food plan is uncomfortable, discuss it with your dietitian; please do not change your food plan by yourself.

The food lists and your meal plan will specify portion sizes and amounts. Since balancing protein and fat with carbohydrate is very important for diminishing cravings, as well as weight gain or loss and nutrient intake, establishing appropriate portion sizes is essential.

To make sure you are getting the correct amounts of the foods specified, we recommend weighing the portions. Most compulsive eaters find that after a period of inappropriate eating, the ability to accurately estimate portion sizes is diminished or distorted. Portion sizes are often underestimated for some foods and overestimated for others.

Weighing (a measurement of weight) is done with a food scale and in ounces, and measuring (a measurement of volume) is done with a measuring cup or cups, and measuring spoons. When weighing foods please be sure foods are in the cooked form. One cup of liquid weighs eight ounces, but one cup of solid food may weigh more or less than eight ounces. Adding liquid by steaming, boiling, etc increases weight and may increase or decrease volume. Reducing liquid by baking, broiling, or roasting decreases weight and may or may not change the volume.

The food plan will specify weights of foods to be used.

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Sugars Definition

A carbohydrate is a food nutrient that provides a major source of energy. The main form of carbohydrate used to generate energy is glucose.

There are 3 types of carbohydrates:

• Sugars

Y Monosaccharides (glucose and fructose)

Y Disaccharides (sucrose and lactose)

• occur naturally in fruit, some vegetables, milk, and sweets

• Starch - foods with many sugar molecules strung together

Y Digestion and absorption depends on the structure of the starch, how it is packaged in the plant source, and how the food is processed and cooked.

• cereals, grains, and legumes

• Fiber - starches that are not digested

The sugars that are absorbed after digestion are responsible for increasing blood glucose concentration. This can be affected by the other foods eaten at the same time, the speed with which your stomach empties, and the way your intestines and other body processes work.

Recommendations

In a compulsive eater, bulimic, or anorexic, large amounts of high-sugar foods are believed to cause the mental and physical responses that lead to inappropriate eating behavior.

Because sugar occurs naturally in many healthy foods, it is not advisable to remove all sugars from your food plan. However, it is necessary to reduce your intake of sugars to the point where your physical cravings are no longer triggered. This point varies from person to person. To begin, this plan removes nearly all added sugars and all high- sugar foods, sweets, and desserts.

Sugars are added to all sorts of foods in processing, and some foods contain primarily sugar and fat. Remove all foods with unnecessarily added sugars. Balance carbohydrate sources with protein and fat. Read labels; in order to reduce food cravings, sugar needs to be after the first four ingredients on the ingredient list. Some people may need to be even more rigorous. If your cravings continue, remove all of the foods with any sugar in the ingredient list. Discuss this matter with your dietitian and do whatever works to best manage your triggers and cravings.

If there are three or more sugars in a food, even below the fifth ingredient, check with your dietitian before using it.

Beware of “sugar-free”

By definition a “sugar-free” product does not contain carbohydrates in a form simple enough to cause dental cavities. The label term “sugar-free” is not related to the amount of carbohydrates in a food. A food labeled “sugar-free” may actually get 100% of its calories from carbohydrates to which you are sensitive!

Sugar has many names, some of which do not sound like sugar. Following is a list of some of the different names for sugar and sugar analogs. Read all the labels on the foods you eat carefully, as sugar is hidden in the most unexpected places.

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Sugars List Avoid foods which contain sugar earlier than the fifth ingredient.

-OSE SUGAR CANE SYRUP MOLASSES

glucose granulated sugar cane juice crystals maple syrup granules sorghum molasses dextrose brown sugar dehydrated cane juice maple syrup Barbados molasses levulose light brown sugar crystals invert syrup blackstrap molasses maltodextrose ribose galactose xyulose

dark brown sugar raw sugar powdered sugar turbinado sugar

unrefined cane juice crystals washed cane juice crystals unbleached evaporated

corn syrup high fructose corn syrup corn sweeteners corn syrup

fruit sweetener

FRUIT JUICE

concentrated fruit juice sweeteners FRUITSOURCE™ clarified grape juice fruit nectars

sucrose beet sugar sugar cane juice corn syrup solids fructose confectioner’s sugar crystals malt syrup crystalline fructose maltose lactose

invert sugar fruit sugar white sugar lo-sugar

crystallized cane juice evaporated cane juice unbleached sugarcane evaporated cane juice

cane syrup ribbon cane syrup sorghum syrup invert sugar syrup

HONEY polydextrose low sugar unbleached crystallized hydrogenated lite sugar

grape sugar Barbados sugar maple sugar

evaporated cane juice organic dehydrated cane juice raw cane crystals Florida Crystals™

glucose syrup heavy, light, or late syrup natural syrup fig, date, or raisin fruit syrup rice syrup brown rice syrup

unfiltered honey filtered honey -OL

maltitol sorbitol mannitol xylitol

CARAMEL

caramel caramel color monosaccharides

MALT

-DEXTRIN barley malt brown rice sweetener disaccharides

barley extract polysaccharides Lactodextrin tapioca dextrin acetylated dextrin amasake demerara

malt syrup maltodextrin malted cereal extract cereal extract succanat rice malt malt flavoring

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Protein Protein sources may be low fat, moderate fat, or high fat. Generally, they contain no carbohydrate. When your food plan is written, the added fat servings are adjusted to the appropriate amount including the fat in your usual protein choices. Do not change your fat serving because of your protein servings; rather, use different protein choices each day or week, creating balance and variety. Choose lean cuts of meat and trim all visible fat. You may leave the skin on poultry products for cooking, and then remove the skin before eating. Fat free proteins are not permitted.

You may use processed vegetarian proteins, such as tofu, tempeh, veggie hot dogs, and veggie burgers, as protein replacements. Check the labels very carefully to be sure that no carbohydrates have been added and to be sure that there is enough protein to replace the meat serving.

Tofu products vary widely in nutrient content, and available products vary by region. Do not overcook before weighing.

Pork and fresh ham are fine as a meat serving; however, processed ham and smoked hams need to be avoided if they have sugar added. Check the labels to be sure. Imitation crab and other imitation fish products are not part of the food plan because of their sugar content.

You may also mix proteins, that is, use one protein for part of your allowance and another for the rest. Weigh proteins after cooking.

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Protein List The proteins in this chart are grouped by category and listed alphabetically.

If there is an ‘x’ under .5:1, this means that .5 ounce of protein by weight is equal to 1 ounce of protein.

Exp: .5 oz of almonds = 1 oz of protein

If there is an ‘x’ under 1:1, this means that 1 ounce of protein by weight is equal to 1 ounce of protein.

Exp: 1 oz of chicken breast = 1 oz of protein

If there is an ‘x’ under 1.5:1, this means that 1.5 ounces of protein by weight is equal to 1 ounce of protein.

Exp: 1.5 oz Morningstar veggie burger = 1 oz protein

If there is an ‘x’ under 2:1, this means that 2 ounces of protein by weight is equal to 1 ounce of protein.

Exp: 2 oz of edamame = 1 oz protein

If there is an ‘x’ under 4:1, this means that 4 ounces of protein by weight is equal to 1 ounce of protein.

Exp: 4 oz of cottage cheese = 1 oz protein

Meat & Protein .5 to 1 1 to 1 1.5 to 1 2 to 1 4 to 1

Beef X Beef or Chicken sandwich steak (Steak-umm) X Canadian bacon X Chicken - canned or shelf-stable pouch X Chicken - breast, leg, or thigh (no skin) X Kidney - beef or lamb X Lamb - including gyro meat X Liver - beef, calf, or chicken X Prosciutto X Pork X Sausage - bratwurst, Italian sausage, knockwurst, smoked sausage, and kielbasa

X

Tuna fish - canned or shelf-stable pouch X Turkey - deli style X Turkey or Capon X Veal X wild game - venison, rabbit, squirrel, pheasant, buffalo, ostrich, duck, or goose

X

Seafood .5 to 1 1 to 1 1.5 to 1 2 to 1 4 to 1 Bass X

Bluefish X Clams X Carp X Catfish X Caviar X Cod X

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Seafood .5 to 1 1 to 1 1.5 to 1 2 to 1 4 to 1 Crab X Flounder X Gefilte fish X Grouper X Haddock X Halibut X Herring X Lobster X Lox X Mackerel X Monkfish X Mullet X Mussels X Orange Roughy X Oysters X Perch X Pollack X Salmon X Sardines X Sashimi X Scallops X Sea Bass X Shrimp X Smelt X Snails X Snapper – Red or Yellowtail X Sole X Squid X Swordfish X Tilapia X Tilefish X Trout X Tuna X

Cheese *no fat-free .5 to 1 1 to 1 1.5 to 1 2 to 1 4 to 1 American X Blue X Brie X Camembert X Cheddar X Cottage Cheese *no more than 8 oz per meal X Farmer’s X Feta X Goat X Gouda X Havarti X

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Cheese *no fat-free .5 to 1 1 to 1 1.5 to 1 2 to 1 4 to 1

Jarlsburg X Laughing Cow (light or reg) 2 wedges = 1 protein X Mozzarella X Muenster X Parmesan X Provolone X Swiss X Ricotta X

Eggs & Egg Equivalents 1 large egg X 2 egg whites + 5 g fat 1/3 cup egg substitute + 5 g fat

Tofu & Vegetarian Options .5 to 1 1 to 1 1.5 to 1 2 to 1 4 to 1 Beyond Meat X Edamame, shelled X Edamame, in pod X Nutritional Yeast X Tofu – soft & silken X Tofu – firm, extra firm, super firm – NO LIGHT TOFU

X

Seitan X Soy crumbles X Spirulina X Tempeh X Veggie burgers – Morning Star, Better’n Burgers, Green Giant Harvest, Boca, Gardein Chick’n Scaloppini or Chick’n Fillets

X

Veggie dog X

Nuts *Unsalted & Raw ONLY .5 to 1 1 to 1 1.5 to 1 2 to 1 4 to 1 Almonds X Brazil nuts X Butternuts X Cashews X Chia X Flax X Hazelnuts X Hemp X Macadamia X Peanuts X Pecans X Pine nuts X Pumpkin seeds X Pistachios X Sesame seeds X Soy nuts X

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Squash seeds X Sunflower seeds X Walnuts X

Beans .5 to 1 1 to 1 1.5 to 1 2 to 1 4 to 1 Adzuki X Black X Cannellini (white kidney beans) X Cranberry X Fava X French X Garbanzo (chick peas) X Great northern X Hyacinth X Kidney X Lentils X Lima X Mung X Navy X Pinto X Soybeans X Turtle X Winged X Yardlong X Yellow X

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Fats Fats are essential to the body for the health of the heart, lungs, and nervous system; many hormones are made from fats. The structure of the skin, hair, and nails depends on dietary fat sources. You must not eliminate all dietary fat; fats should comprise 20-30% of calories.

You may use any mixture of fats that totals the number of grams specified on your food plan.

The fat list is divided into unsaturated and saturated. Emphasize monounsaturated and polyunsaturated fats such as olive oil, canola oil, and corn oil, in preference to saturated fats. Monounsaturated and polyunsaturated fats are vegetable in origin and liquid at room temperature, while saturated fats, such as shortening or butter, are animal in origin, and are solid at room temperature. Most nutrition authorities now recommend complete avoidance of trans fats, which are made when oils are hydrogenated, because they greatly increase your risk of heart disease.

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Fat List Do not cook with allotted fat. Use cooking spray or fill a spray bottle with olive oil or chicken broth. Use the table below to determine how many grams, by weight, you will need in order to satisfy 5, 10, or 12 g fat.

Monounsaturated & Polyunsaturated 5 g fat 10 g fat 12 g fat Margarine 7 14 17 Whipped margarine 10 20 24 Mayonnaise 7 14 17 Oil (canola, corn, safflower, soybean, sunflower, olive, peanut)

5

10

12

Regular salad dressing (blue cheese, Caesar) 10 20 24 Avocado 28 56 67 Guacamole 38 76 91 Basil pesto 16 32 38 Green olives

small 10 olives 20 olives 24 olives sliced 32 64 77

Black olives small 12 olives 24 olives 29 olives medium 10 olives 20 olives 24 olives jumbo 8 olives 16 olives 19 olives sliced 32 64 77

Kalamata olives 7 olives 14 olives 17 olives

Saturated 5 g fat 10 g fat 12 g fat Bacon 12 24 29 Turkey bacon 45 90 108 Turkey Pepperoni 38 76 90 Beef or Pork Pepperoni 12 24 28 Butter 7 14 17 Whipped butter 6 12 14 Sour cream 30 60 72 Reduced fat sour cream 52 104 125 Regular cream cheese 15 30 36 Whipped cream cheese 25 50 60 Light cream cheese 30 60 72 Mascarpone cheese 11 22 26 Unsweetened coconut flakes 7.5 15 18 Coconut milk 37 74 89 Light coconut milk 89 178 214

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Use the table below to determine how many grams of nuts or seeds you will need in order to satisfy 5, 10, or 12g fat.

Examples: 10 g of almonds by weight = 5 g of fat

7 g of pecans + 8 g of walnuts by weight = 10 g of fat

Nuts & Seeds *Unsalted & Raw ONLY 5 g fat 10 g fat 12 g fat Almonds 10 20 24 Brazil nuts 8 16 19 Butternuts 9 18 22 Cashews 12 24 29 Chia Seeds 16 32 37 Flax seeds 12 24 28 Hazelnuts 8 16 19 Hemp Seeds 11 22 26 Macadamia 7 14 17 Peanuts 10 20 24 Pecans 7 14 17 Pine nuts 8 16 19 Pistachios 11 22 26 Pumpkin Seeds 23 46 56 Sunflower seeds 10 20 24 Sesame seeds 10 20 24 Walnuts 8 16 19

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Fats – Alternate Method Use this alternate method to calculate fats using tablespoons and teaspoons.

Monounsaturated & Polyunsaturated 5 g fat 10 g fat 12 g fat Margarine 1 tsp 1 Tbsp 1 Tbsp + 1 tsp Whipped margarine 2 tsp 1 Tbsp + 1 tsp 1 Tbsp + 2 tsp Mayonnaise 2 tsp 1 Tbsp 1 Tbsp + 1 tsp Oil (canola, corn, safflower, soybean, sunflower, olive, peanut)

1 tsp

2 tsp

1 Tbsp

Regular salad dressing (blue cheese, Caesar) 2 tsp 1 Tbsp + 1 tsp 1 Tbsp + 2 tsp Avocado 2 Tbsp 4 Tbsp 5 Tbsp Guacamole 2 Tbsp 4 Tbsp 5 Tbsp Basil pesto 1 Tbsp 2 Tbsp 2 Tbsp + 2 tsp Green olives

small 10 olives 20 olives 24 olives sliced 2 Tbsp + 1 tsp 4 Tbsp + 1 tsp 5 Tbsp + 1 tsp

Black olives small 12 olives 24 olives 29 olives medium 10 olives 20 olives 24 olives jumbo 8 olives 16 olives 19 olives sliced 2 Tbsp + 1 tsp 4 Tbsp + 1 tsp 5 Tbsp + 1 tsp

Kalamata olives 7 olives 14 olives 17 olives

Saturated 5 g fat 10 g fat 12 g fat Bacon 1 slice 2 slices 2 ½ slices Turkey bacon 2 slices 4 slices 5 slices Turkey Pepperoni 1 oz 2 oz 3 oz Beef or Pork Pepperoni .5 oz 1 oz 1.25 oz Butter 2 tsp 1 Tbsp 1 Tbsp + 1 tsp Whipped butter 2 tsp 1 Tbsp + 1 tsp 1 Tbsp + 2 tsp Sour cream 2 Tbsp 4 Tbsp 5 Tbsp Reduced fat sour cream 3 Tbsp + 2 tsp 7 Tbsp + 1 tsp 8 Tbsp + 2 tsp Regular cream cheese 1 Tbsp 2 Tbsp 2 Tbsp + 2 tsp Whipped cream cheese 1 Tbsp + 2 tsp 3 Tbsp 3 Tbsp + 2 tsp Light cream cheese 2 Tbsp 4 Tbsp 5 Tbsp Mascarpone cheese 2 tsp 1 Tbsp + 1 tsp 1 Tbsp + 2 tsp Unsweetened coconut flakes 1 Tbsp + 2 tsp 3 Tbsp 3 Tbsp + 2 tsp Coconut milk 1 oz 2 oz 2.4 oz Light coconut milk 3 oz 6 oz 7 oz

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Numbers listed below are pieces, unless otherwise noted. *Use heaping Tbsp and tsp for walnuts and butternut; all others should be level **Counts are for the whole nut

Nuts & Seeds

5 g fat

10 g fat

12 g fat

1 oz protein (.5 oz by wt)

Almonds 8 17 20 12

Brazil nuts 2 3 4 4

Butternuts* 1 Tbsp 2 Tbsp 2 Tbsp + 2 tsp 2 Tbsp

Cashews** 6 11 14 8

Chia Seeds 1 Tbsp 2 Tbsp 2 Tbsp + 2 tsp 1 Tbsp

Flax seeds 1 Tbsp 2 Tbsp 2 Tbsp + 2 tsp 1 Tbsp + 1 tsp

Hazelnuts 6 12 14 13

Hemp Seeds 2 tsp 1 Tbsp + 1 tsp 2 Tbsp 1 Tbsp + 1 tsp

Macadamia 5 9 11 9

Peanuts** 11 21 26 15

Pecans (halves) 5 9 11 8

Pine nuts 2 tsp 1 Tbsp 1 Tbsp + 1 tsp 1 Tbsp + 1 tsp

Pistachios (shelled) 16 31 38 24

Pumpkin Seeds 2 Tbsp 4 Tbsp 5 Tbsp 1 Tbsp + 1 tsp

Sunflower seeds 2 tsp 1 Tbsp 2 Tbsp 2 Tbsp

Sesame seeds 2 tsp 1 Tbsp 2 Tbsp 1 Tbsp + 2 tsp

Walnuts* 1 Tbsp 2 Tbsp 2 Tbsp + 2 tsp 2 Tbsp

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Cereals, Carbohydrates and Grains Weigh carbs, such as rice, after cooking. Try some carbs that are new to you, and experiment with seasonings, sauces, and flavors.

One ounce of cold cereal or uncooked hot cereal is equivalent to 3 carbs. Weigh hot cereal, such as oatmeal, before cooking; the amount of water absorbed can vary greatly and will change the weight.

Rice cakes are acceptable but since they have fewer nutrients, you may feel hunger quickly after eating them.

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Cereals, Carbohydrates and Grains List 1 oz of cereal = 3 oz carbs All complex carbs and grains are 1:1, unless otherwise noted, such as pumpkin (2:1) Exps: 1 oz barley = 1 oz carb

2 oz pumpkin = 1 oz carb

Cold Cereals Hot Cereals Complex Carbs/Grains Uncle Sam’s Cereal oat bran amaranth shredded wheat oatmeal barley spoon-sized shredded wheat rolled oats beans shredded wheat and bran Irish oatmeal buckwheat Erewhon Corn Flakes cream of brown rice bulgur puffed brown rice cream of whole rye corn: white, yellow, sweet, corn on cob (6

in long) puffed rice kasha farro puffed corn buckwheat groats green peas puffed millet barley buds hummus puffed barley creamy rice kamut puffed kashi rye wheat berries kasha puffed wheat rye berries lentils puffed whole wheat 7 grain, rye flakes, barley flakes millet Wheat Germ Pritkin Hearty Multigrain Hot Cereal parsnips Kashi Pilaf Erewhon 12 grain hot cereal plantain Seven Grain Kashi Cereal millet potatoes: white, gold, russet, Yukon

quinoa pumpkin – canned (2:1)

hominy (yellow corn grits) quinoa

wheat hartz rice: basmati, brown, Creole, Jasmine, pecan, texmati, and wild rye berries (no yellow, white or red rice)

wheat bran spelt

Wheatena split peas

whole corn grits black-eyed peas

sweet potato

wheat berries

ALL winter squash 2:1: acorn, butternut, hubbard pumpkin, spaghetti

yams

yucca

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Abstinent Cracker List

Crackers may be used at a maximum of once per day. Calculate crackers in terms of calories per ounce, versus weight. Exceptions on flavors are listed below. All other flavors are permitted.

Ezekiel Wraps

Wrap Itz – 100% Stone Ground Whole Wheat ONLY

Rice Cakes – brown, plain, or lightly salted ONLY

Ryvita Crackers – no Sesame Rye

Ry Krisp – no Sesame

Wasa – no Sesame or Light Rye

Mary’s Gone Crackers – no Super Seed Abstinent Prepared Frozen Carbs

Dr. Praeger’s spinach or broccoli pancakes

2 pancakes = 3-4 oz carb

Alexia’s Garlic Rosemary & Olive Oil Roasted Potatoes

1:1 (i.e.: 3 oz potatoes cooked = 3 oz carb)

Additional Carbs

Arrowroot is a white powder extracted from the root of a West Indian plant, Marantha arundinacea. It looks and feels like cornstarch. Arrowroot may be used as a carb, to make crepes, or it may be used as a condiment to make fruit jellies or sauces.

• As a carb, 1 Tbsp of arrowroot = 1 oz cooked carb • As a condiment, up to 3 tsp “free” are permitted per day for use in a recipe.

Chestnuts are unique compared to other nuts because of their low fat and high moisture content. They are comprised primarily of carbohydrates, making them more nutritionally akin to a grain. Chestnuts can be counted as carb using a 1:1 ratio.

• 1 oz chestnuts = 1 oz carb

1 oz carb = 40 calories 3 oz carb = 120 - 150 calories

4 oz carb = 160 - 180 calories

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Fruits All of the calories in fruit come from the fruit sugar named fructose. Fructose is digested and absorbed as quickly as any sugar; after absorption it is sent to the liver to be converted into glucose, glycogen, and triglycerides. If you eat fruit alone or on an empty stomach, you may find yourself craving or extremely hungry 60-90 minutes later. It’s recommended that you eat fruit with protein or milk servings or with your meal to slow down the absorption of the sugar.

Measuring fruit servings

Fruit cores, peel, and seeds add very little weight. If you choose, you may weigh fruit in the grocery store to 1 oz more than your prescribed weight per piece of fruit. Some fruits are more concentrated than others, and are measured to ½ the amount required by your food plan. For example, if you wish to eat grapes and are required to eat 6 oz of fruit, you would weigh out 3 oz of grapes. Additionally, when weighing out frozen fruit, add 1 more oz in weight to account for the ice.

Canned Fruit

Weigh or measure canned fruit to your food plan specifications. Use only fruit that is packed in water or its own juices. If packed in its own juices rinse and drain 3 times before consuming. Use applesauce which is natural and unsweetened, but avoid the “No Sugar Added” applesauce because it contains added fruit concentrate. Applesauce may be weighed or measured to your food plan’s specifications. Do not use canned fruit sweetened with Splenda, unless verified by the nutritionist. Fruit juices and dried fruit are not permitted on the food plan.

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Fruit List The fruits in this chart are listed alphabetically.

If there is an ‘x’ under .5:1, this means that .5 ounce of fruit by weight is equal to 1 ounce of fruit.

Exp: .5 oz of grapes = 1 oz of fruit

If there is an ‘x’ under 1:1, this means that 1 ounce of fruit by weight is equal to 1 ounce of fruit.

Exp: 1 oz blueberries = 1 oz of fruit

Fruit .5 to 1 1 to 1

Apples X Applesauce X Apricots X Bananas X Blackberries X Blueberries X Boysenberries X Cherries (20) X Clementines X Cranberries X Figs X Fruit Cocktail X Grapes X Goji berries (frozen) X Grapefruit X Kiwi X Mango X Mandarin Oranges X Melon (honeydew, cantaloupe, casaba) X Nectarines X Oranges X Papaya X Peaches X Pears X Persimmon X Pineapple X Plums X Pomegranate X Raspberries X Strawberries X Tangelos X Tangerines X Watermelon X

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Vegetables 5 Reasons to Eat Vegetables

(1) They contain an incredible variety of vitamins, minerals, and other nutrients that are not found in other foods.

(2) They are low in sodium and are excellent sources of dietary fiber.

(3) They contain chemicals that may slow the development of cancer cells at a variety of stages of its development.

(4) They give you the opportunity to chew! And their volume makes you feel full.

(5) They slow down the absorption of the other foods you eat, so your meal lasts longer.

Choose a variety of vegetables to maximize their nutrition content.

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Vegetable List

alfalfa sprouts * Weigh artichokes whole, after cooking, to twice your food plan

*artichoke specifications.

artichoke hearts

asparagus With Caution:

baby corn (canned) V-8 juice**

bamboo shoots tomato juice**

beans (yellow, green, wax, butter, or Italian) vegetable juice**

bean sprouts * *1 cup (8 oz) may be substituted for 4 ounces of vegetables. You may only use V-8 juice during travel greater than 8 hours or illness.

beets Speak with your dietitian before using.

bok choy Vegetables can be used for snack 1X/day (instead of your fruit)

broccoli Vegetables may not be made into “chips”

brussel sprouts

cabbage (red, savoy, green, purple, Chinese, or butterbur)

carrots

cauliflower

celery

celeriac

chicory

cucumbers

dill pickles

eggplant

fennel

garlic

greens (such as beet, Swiss chard, chicory, escarole, mustard, collard, turnip, dandelion, kale, endive, watercress, or spinach) jicama

snow peas

sugar snap peas

tomatoes (includes cherry tomatoes and grape tomatoes)

turnips, yellow or white

water chestnuts

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Milk and Yogurt Milk is a powerhouse of whole protein, calcium, B vitamins, minerals, and vitamin D. It is a well-balanced source of proteins, fat, and carbohydrate.

When you choose milk and milk products, they will always contain carbohydrates. Read labels and compare them with plain low fat milk to be sure that no sweeteners have been added. Check for starches, gums, stabilizers, and other additives to which you may be sensitive. Choose non-fat or low-fat milk products.

Lactose intolerance means that the body is unable to digest the carbohydrate in milk named lactose. If you are lactose intolerant, one option is to try Lact-Aid milk or Lact-Aid or Lactase pills or drops to change the carbohydrate into a form you can handle.

Another option is to use a milk substitute made from soy, rice, oat, barley, or a combination of grains. Read these labels carefully; these products often have sugars or other carbohydrates added to them and may have much less protein than cow’s milk.

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Milk List Milk may not be substituted for protein at lunch or dinner.

1 cup milk, skim or 1% or 2%

1 cup low-fat buttermilk

1/2 cup evaporated skim milk

1/3 cup non-fat dry milk powder

6 -8 oz of plain or Greek yogurt (fat free or low fat)

1 cup soy milk *

1 cup soy rice milk*

1 cup sweet acidophilus milk

1 cup goat’s milk

3/4 cup kefir

*Be certain that these products are calcium fortified, have as much protein as regular milk, and have no added sugars.

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Flour/Starch This basic food plan removes all flour and flour-containing foods. Because flour is made of long chains of sugar molecules, which are quickly absorbed, your body’s reaction to flour may be similar to its reaction to sugar. Additionally, your sensitivity to flour may increase when sugar is removed. If you are sensitive to a particular type of flour, you are likely to be sensitive to all flours - wheat, rye, oat, corn, barley, soy, spinach, millet, artichoke or kidney bean flour. People vary widely in their sensitivities to flours, and all food sensitivities can change over time. It is recommended that you remove these foods at the beginning of your recovery. After a period of abstinence, you may wish to discuss this matter with your dietitian.

White flour also may be called wheat flour, enriched flour, or unbleached enriched wheat flour. Durham semolina and red winter wheat are also names for flour. The name for corn flour is cornmeal; foods made with this product are flour foods. Avoid all these foods.

Corn starch, wheat starch, tapioca starch, and modified food starch are not sugars but are such highly refined flours that the body frequently reacts to them as though they were sugars. Avoid products in which they are listed before the fifth ingredient.

On food labels, manufacturers must state each ingredient in the original form with which they began their manufacture of the food. For instance, if a manufacturer bought whole corn and ground it into corn flour the manufacturer can list “corn” on the label. Corn chips, tortillas, and similar products are all made with corn flour. Rice and barley pastas are also made from flours. Read labels carefully and use your intuition, your common sense, and good judgment. Ask for help from your nutritionist whenever you need it.

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Sweeteners Five non-nutritive artificial sweeteners are approved by the FDA for use as sweeteners:

• Saccharin - sold as Sweet ‘N Low, Sweet Twin, Sweet ‘N Low Brown, Nectasweet

• Aspartame - sold as NutraSweet, Equal, or Sugar Twin

• Acesulfame K - sold as Sunett, Sweet & Safe, Sweet One

• Sucralose - sold as Splenda

• Stevia - sold as Sweet Leaf, Stevia in the Raw, Better Stevia

• Eryrthritol - sold as Truvia, PureVia

All are much sweeter by volume than sugar. Because of this they are sold in packets with an extender, or bulk-adding product like dextrose or maltodextrin. These extenders are sugars or sugar analogs - other types of sugar-like foods. The current trend is to blend these high intensity sweeteners with each other or with sugars or sugar analogs to create the desired sweetness, texture, and consistency for the product. Depending on your individual sensitivities, the sweeteners themselves can affect many body processes, or the sweet taste may call up memories of binge or trigger foods, or of your past binge eating experiences.

If you are sensitive to one or the other of these products, you may notice increased anxiety, irritability, headaches, and cravings after using it. If you are having unexplained cravings or difficulty following your food plan, look at your use of sweeteners. If you suspect they may be causing problems for you, remove them.

Check with your doctor about all of these products if you are pregnant or lactating or have other medical problems which may be affected by them.

If you find yourself mixing sweeteners or using more than 6 packets or “stretching” (counting, waiting for the next one, or mixing to sneak in an extra one), then you need to avoid them.

Daily Allowance & Guidelines

• Maximum of 6 packets • Maximum of 2 packets per food or beverage item • No liquid sweeteners (ie: Stevia drops)

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Sugar-Free Gum, Mints and Artificially Sweetened Drinks Sugar-Free Gum and Mints: All sugar-free gum and mints contain sugar alcohols (sorbitol, maltitol, xylitol, etc.), plus NutraSweet (aspartame) or other artificial sweeteners. Sugar-free gum and mints are not recommended for regular use, because the sugar alcohols or the concentrated sweeteners can be triggering. You may have no more than 5 mints or 5 sticks of sugar-free gum per day. If you find yourself having used all 5 sticks or mints in the first half of the day, eliminate them entirely. If you find yourself with more than one stick of gum or mint in your mouth, eliminate all gum or mints.

Artificially Sweetened Drinks: You may have up to 24 oz of an artificially sweetened drink per day. This includes all Crystal Light, diet sodas, and diet Snapple products. You may have up to 1 Crystal Light packet, or similar product, per day. Squeeze liquid flavored beverage mixes are not permitted.

Caffeine: Caffeine stimulates the central nervous system and can produce many effects throughout the body. Primarily, it increases heart rate and the capacity for muscular work. If you are tired, sleepy, or bored, caffeine may make you feel more wide-awake and able to focus on mental and manual tasks.

Excessive caffeine consumption may lead to anxiety, restlessness, irritability, sleep disorders, headache, and heart palpitations. You may also have troublesome cravings and increased hunger with excessive caffeine use. A reasonable amount of caffeinated beverages would be two 8 oz cups per day. Work with your dietitian to find the amount that is best for you.

Fluids: Your weight and sense of well-being are affected by the amounts of fluids you drink. Water is vital for every chemical reaction of digestion and metabolism, for joint regulation, and for brain function. You do not have to drink only water. You may also choose seltzer, flavored seltzer, sparkling water, or decaffeinated herbal teas. Estimates currently vary about the amount of water needed. Many authorities say that we should drink 8 to 10 cups of fluid per day, others say more or less. You may need even more than 10 cups per day, especially in early recovery, to wash out high sugar, high fat, or high salt foods, or your binge or trigger foods and their effects, and to stabilize blood volume. People with a lot of weight to lose often need additional fluids - some authorities recommend adding 1 cup of fluid for each 25 pounds over normal body weight. Drink extra fluids also if you exercise briskly or if the weather is hot and dry. Create a pattern for fluid intake to distribute your fluid intake evenly through the day.

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Beverages, Condiments and Sauces Artificial Sweeteners: 6 packets per day, not more than 2 packets per meal.

Artificially Sweetened Drinks: 24 oz. per day of artificially sweetened drinks

• diet soda, diet Snapple or any water flavored with artificial sweetener

• 1 packet per day of Crystal Light or equivalent per 16 oz of water

Broth: 2 cups of broth or consommé per day

• Beef, chicken, or vegetable. Canned broth must not have sugar or flour products in the first five ingredients

Butter Spray: 10 sprays per meal

Chopped Vegetables: 4 oz chopped vegetables per day for flavoring other foods

Coffee: 2 cups of 8 oz of coffee per day

Condiments: sugar and alcohol-free, no more than 3 condiments per meal

• 2 Tbsp of ketchup, mustard, hot sauce, soy sauce, tamari, vinegar

• 1 tsp of miso, wasabi, anchovy paste, horseradish, pimentos, alcohol-free flavoring extracts

• 2 Tbsp of Heinz Reduced sugar Ketchup sweetened with Splenda = 1 Splenda packet

• 2 Tbsp of Walden Farms calorie free, sugar free dressings *Must be approved by the Nutritionist

• up to 3 tsp of arrowroot as a thickener for fruit filling or sauces

Dairy & Alternative: 4 oz of milk OR unsweetened almond milk OR yogurt plus 1 egg white for coffee and/or food preparation

Flavors: Sugar free syrup must be approved by the Nutritionist before initial use

Fruit Condiments: ½ lemon or lime slice up to six times a day for tea or seltzer

Herbs and Spices: 2 tsp of any herb, spice, or herb mixture you choose per meal plus any herb, spice, or mixture as directed by a recipe

• 1 tsp table salt per day

Sauces: ½ cup sauce per meal

• Sugar-free barbecue sauce, picante sauce, tomato sauce, salsa

• less than 2 g fat and less than 60 calories per half cup

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Metric Equivalents

Equivalents for Different Types of Ingredients Standard

Cup Fine

Powder Grain Granular Liquid

Solids Liquid

1 140 g 150 g 190 g 200 g 240 ml

3/4 105 g 113 g 14 3g 150 g 180 ml

1/2 70 g 75 g 95 g 100 g 120 ml

1/3 47 g 50 g 63 g 67 g 80 ml

1/4 35 g 38 g 48 g 50 g 60 ml

Dry Ingredients by Weight To convert ounces to grams multiply the

number of ounces by 30.

1 oz = 1/16lb = 30g

4 oz = 1/4lb = 120g

8 oz = 1/2lb = 240g

12 oz = 3/4lb = 360g

16 oz = 1 lb = 480g

Liquid Ingredients by Volume 3 tsp = 1 tbsp = 1/2 fl oz = 15 ml

1 pt = 2 cups = 16 fl oz = 480 ml 1 qt = 4 cups = 32 fl oz = 960 ml

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Meal Ideas • Chicken fried rice with egg beaters and veggies

• Chicken/Tuna salads with rye crisps or atop salad, dressing, veggies, beans

• Salsa Chicken or Boca (with cheese)and refried black beans with salad, lettuce shreds or vegetables (peppers)

• Chicken/tuna/tofu stir fry w/ lettuce cups, crushed cashews, vegetable mix (celery, water chestnuts, red pepper, onion, etc.), and rice and/or baby corn.

• Tofurky warmed in skillet with marinated or roasted vegetables and baked potato with side salad, splitting dressing between turkey and salad or butter for potato

• ¾ C omelet with 4 oz veggies, 3 oz fruit in oatmeal with butter in oats and eggs, or Newman’s garlic dressing

• Tuna or salmon steak marinated and grilled with balsamic vinegar and garlic, green beans and rosemary roasted potatoes

• Grilled chicken with garlic broccoli or spinach, tossed with pecans and dressing, served with corn on the cob, rice or potatoes

• Roasted red peppers stuffed with rice, egg white, chopped onions, garlic, Newman’s garlic olive oil and tofu

• Tuna melt atop rice cakes with side salad and dressing or nut

• Tofurky atop rice cakes with tomatoes pickles and cheese slices and side salad; dressed salad and drizzled “sandwich”

• Lentil soup (8 oz bean, 2 oz onion/celery, Newman’s dressing) with potato/rye crisp/rice cake/rice and side salad

• Tofu/Chicken & rice soup with carrots, celery, tomato, broccoli and olive oil

• White bean puree with spinach, tomato, onion, side salad (or not), and rye crisps (or not)

• Carrot puree with yucca chunks, side salad and chicken (curry recipe) (or rye crisps) and walnuts

• Tofu grilled with tomatoes and onions atop greens, rye crisps and nut or dressing

• Boca salad with corn and/or rice, atop lettuce shreds, red/pepper blend, onions, cheese and ranch or Caesar in blend or on top

• Boca & refried bean “pate” in lettuce cups with dressing/walnut, peppers and salsa

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Quick Reference Guide • No fat-free cheese of any kind, including cottage cheese

• Fat-free yogurt and milk is OK

• Cottage cheese is 4:1

• Laughing Cow cheese - 2 wedges = 1 protein for both light and regular

• Beans as protein 2:1 as carb 1:1

• All nuts and seeds as protein .5:1 as fat, check the label for fat grams

• 2 egg whites + 5g fat = 1 protein

• 1/3 cup egg substitute + 5g fat = 1 protein

• Hummus is a carb 1:1

• Pumpkin and all winter squash are carbs that are 2:1

• Fruit may replace vegetable in a recipe 1x per week

• Add 1 oz when weighing frozen fruit

• Vegetable for snack only 1x per day

• Crackers no more than 1x per day

• No more than 3 loaves per week as a meal

• No more than 6 packets of sweetener per day

• No more than 5 pieces of gum or mints per day

• No squeeze liquid sweeteners or liquid beverage mixes

• Add 2 oz to raw vegetables if weighed before cooking

• Add 1 ½ oz to ANY raw protein if weighing before cooking

o Exp: 3 oz needed = 4 ½ oz raw white fish + 1 ½ oz raw fish = 6 oz total raw weight

• Avoid foods which contain flour or sugar before the 5th ingredient

• Avoid foods that contain three or more sugars, even below the fifth ingredient

• No dessert flavored coffees (ie: Godiva Chocolate or Strawberry Shortcake)

• Nut and vanilla flavored coffees are acceptable.

• Look for the buzz words flour and starch on food labels and AVOID these foods; wheat is OK, unless you have been advised to follow a gluten-free plan

• Coffee-house guidelines:

o Must be approved and included on pass

o ONLY hot or iced: regular or decaf coffee, unsweetened tea

o Add milk and sweetener to your own beverage-- should not be added by barista

o No other beverages are permitted (ie: lattes, cappuccinos, sugar free syrups)