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Susan Cowden, MS

Eating Disorders Blog


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A Review of Internet-Based Treatment Shows Mixed Results

Sunday March 30, 2014

As more and more of our lives and businesses are conducted online, the mental health world is no different.  Many therapists have looked into providing services online, whether it be through video-conferencing or e-mail.  Other providers have designed online based treatment programs and self-help software for various issues as well.  Online and computer-based treatment options have many benefits such as being cost effective and anonymous, but, are these treatment options actually effective?

A recent review of the literature by researchers in the Netherlands examined twenty-one different studies that looked at the efficacy of internet-based treatments on eating disorder symptoms.  Although the majority of the studies did show improvement in symptoms, the results were truly mixed.  For example, the most improvement was seen in people suffering from binge eating and purging symptoms with little improvement seen in people struggling with restrictive eating symptoms.  And, as might be expected, the most improvement was seen in people with the fewest and least severe eating disorder symptoms as well as those without any other types co-occurring issues.

One of the major limitations of this research is that all of the studies compared internet-based treatment options to people who were on a waiting list for treatment (not currently receiving treatment) rather comparing them than to traditional face-to-face therapy.  The authors did note that there is currently a study being done to compare internet-based treatment with face-to-face cognitive behavioral therapy so hopefully more information on these types of treatments will be forthcoming in the future.

In short, while internet-based treatment may be helpful for a select few people who have few symptoms and are extremely self-motivated, it's probably not for everyone (or even most people).  It may also be important for treatment providers to work the kinks out of any current internet-based programs to see how they can be made more helpful.

Do you have any experience with internet-based therapy, either as a primary form of treatment or as an adjunct to traditional therapies?


Aardoom, J.J., Dingemans, A.E., Spinhoven, P., &Van Furth, E.F. (2013). Treating eating disorders over the internet: A systematic review and future research directions. International Journal of Eating Disorders, 46(6). 539-552.

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America's Outcry Over The Biggest Loser

Friday February 7, 2014

The past couple of days there have been a storm of tweets and news articles related to the outcry regarding the weight and appearance of the most recent winner of The Biggest Loser, Rachel Frederickson.  Many people are saying that she appears to be anorexic or unhealthy at best. I don't know and won't comment on if Frederickson is anorexic. Why? Because I only know her weight and her appearance and eating disorders are not diagnosed on these two criteria.  For what it's worth, according to the numbers presented on the show, Frederickson now has a BMI that puts her in the 'underweight' category.  Although the use of BMI as a measure of health is limited, at best, being underweight is actually considered more dangerous than to be overweight.

I do have a multitude of thoughts about the show and it's been somewhat of a challenge to organize them coherently as I could get on a soapbox for a while.  I think that I may have watched one episode during one of the initial seasons and was so dismayed by it that I haven't watched it since.  So, in case you're like me and you don't know exactly how the show works, here it is in a nutshell: Essentially, fifteen contestants stay at a ranch where they work with trainers for a period of 3-4 months (I couldn't find the exact timeline) and then return to their homes where they lose weight for another 6 months and then return for the finale.  Over the course of the show, contestants are sent home, but can achieve 'immunity' by losing the most weight each week.  The final winner is determined by who loses the most weight, by percentage, since the beginning of the show.  It is my understanding that the method of weight loss is drastic calorie restriction and exercising up to six hours per day.

One former contestant, Kai Hibbard, from the third season of the show has spoken out and has said that being on the show triggered an eating disorder for her.  In an interview, Hibbard recounts how physicians on the show recommended an electrolyte supplement but that trainers encouraged the contestants to "throw it out" because it would result in water retention (and higher weights).  She also reports that, "the lighter I got during that T.V. show, the more I hated my body." I suspect that she's not the only one.  I'd also venture that because of the complicated relationship many of these contestants have with food and weight, that some may have already had an eating disorder before the show began.

Other than the obvious disordered behaviors such as calorie restriction and over-exercise, I also think it is worth pointing out that weight is the only measure of 'health' seen on this show.  Although certainly some of the contestants have grown larger than their genetics alone would have dictated, there is no mention of their blood pressure, cholesterol or other measures of health.  Were these contestants actually unhealthy before they began the regimen?  Did these measures of health actually improve over the course of the show?  For those who used food as a coping mechanism, do they now have other ways to cope with life's stresses?  What is their relationship with food and their bodies like now?  My guess is that none of the answers to these questions would make for a successful television show.

It is extremely troublesome anytime that people are willing to sacrifice their health (both physical and mental) in the name of weight loss.  Although I am glad that Americans are finally reacting negatively to this show, I worry that Rachel Frederickson's appearance is only the tip of the iceberg.


Flegal, K., Kit, B., Orpana, H., & Graubard, B. (2013). Association of all-cause mortality with overweight and obesity using standard body mass index categories: A systematic review and meta-analysis. Journal of the American Medical Association, 309(1). 71-82.

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Seeing Yourself Through a Child's Eyes

Thursday January 23, 2014

If you are a regular reader, you have likely noticed that the past few months I have been posting sporadically, at best. This is a result of the birth of my second child. As such, I've been busy and sleep-deprived much of the time lately. If you've had children you likely know that there are some days when I am lucky to shower and put on 'real' clothes rather than hanging out all day in pajamas or yoga pants.

I am also acutely aware of the dramatic changes that have occurred in my body through both the pregnancy and post-partum time periods. Going to my closet is currently an adventure to see what will fit and how it may fit differently than it did prior to my pregnancy. Sometimes I am excited to put on an old favorite, while other times I am disappointed that something doesn't fit. All of this culminates into not always feeling like 'myself' and often feeling self-conscious in the way that I look.

However, a few days ago, my three-year-old boy padded into my room in the morning and crawled up beside me in bed to wake me up. As he sat there, he began stroking my tangled, slept-on hair and said, "Mama, I love your crazy hair." My heart melted, but he continued, "I love nose, I love your eyes," running his hands over my face. I am amazed by his sweet innocence and the fact that he doesn't know that my hair isn't "supposed" to be crazy and tangled or that I feel more confident with my makeup done. He simply sees me and loves me as I am.

Imagine what it would be like if we could all accept each other in this simple way - or even more importantly if we could accept ourselves in this way. How would you think about yourself differently if you saw yourself through a child's eyes?

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Happy New Year!

Tuesday December 31, 2013

It's hard to believe that 2014 is already here.  It is always surprising to me how quickly the holiday season goes by and also how nice it is to get back into a regular routine and schedule.  My holidays consisted of tons of traveling so I am thankful to be back in my own bed and home.

The new year can symbolize a new beginning for many people, especially those who are struggling with something or going through a difficult time in their lives.  I've had multiple clients tell me that they want a new year to be eating disorder-free or to be a year of recovery.  I think that is a wonderful idea.  However, I also think it is important to be realistic with your goals for the year.  Try to make goals that are achievable and flexible.  Eating disorder recovery is imperfect and by asking yourself for perfection, you may be setting yourself up for disappointment.

Did you make resolutions this year?  What are they?  Don't worry if you haven't made them yet, you can make resolutions any time that you like!

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Reader Stories Wanted!

Friday November 29, 2013


I have recently added a category entitled 'personal stories.' I am looking forward to adding profiles of celebrities and reviews of eating disorder memoirs over the coming months. However, I also want to include the stories of real-life people who are struggling with eating disorders and are in recovery from readers (that means you!)

Please consider sharing your recovery story.  If you don't see a question or topic that you are interested in writing about now, please keep an eye out as others will be added. You are also welcome to suggest topics to me at eatingdisorders@aboutguide.com.  You are also welcome to share about yourself or discuss topics related to eating disorders and recovery in the forum.

As you write, please remember that all submissions are edited for content prior to publication.  The following link provides guidelines to keep in mind.

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Should You Try Yoga?

Wednesday October 30, 2013


Pressures to conform one's body to the 'thin ideal' are extremely prevalent in our society today - so much so that it is considered somewhat 'normal' to be unsatisfied and critical of one's body.

In an effort to find out what fights against negative body mage and self-objectification, researchers at San Jose State University in California, interviewed adult women who practice yoga on a regular basis.  Out of all of the participants, 74% reported that at some point in their lives they had struggled with their weight or with negative body image.  Interestingly, 75% of participants reported that their body acceptance and appreciation increased after developing a yoga practice.

Not only did these women report increased body acceptance, but they also reported that they attribute positive feelings and a feeling of well-being to their yoga practice.  They also expressed "greater connection to themselves, to others, and to their notion of the divine" and were more likely to practice intuitive eating.  The researchers concluded that yoga seems to have helped these women by improving physical and emotional awareness and providing a method for grounding and introspection or meditation.

Do you practice yoga as part of your recovery?  What has been your experience?


Dittman, K.A. & Freedman, M.R. (2009). Body awareness, eating attitudes, and spiritual beliefs of women practicing yoga. Eating Disorders, 17. 273-292.

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Early Childhood Sleep Problems, a Precursor to Eating Disorders?

Tuesday August 27, 2013

Researchers, clinicians, and sufferers are often interested in finding out what leads to eating disorders, what causes them, and how we can predict them (if at all). A recent research study done in Norway and published by the Journal of Eating Disorders sought to do just that.

Researchers used results from a 15-year-long longitudinal community study to investigate risk factors from early childhood (before age 5) for adolescent eating problems. The study began with 921 mothers completing questionnaires regarding their 1 ˝ year old child. 784 mothers completed questionnaires at age 2 ˝ and 737 at age 4 ˝. When the children were 16 years old, 373 mothers also completed a questionnaire about eating problems called the Eating Attitudes Test.

The study looked at several possible risk factors from early childhood including picky eating in early childhood, sleep problems, internalizing problems, shyness, and emotionality. Interestingly, the only risk factor that was associated with the development of eating problems in adolescence was early childhood sleep problems.

Although this does not mean that sleep problems cause eating disorders, it may mean that there is some type of psychological or biological problem that results in both sleep problems in early childhood and eating problems in adolescence. However, given that this is the only study to show a such a correlation, the results must be duplicated before anyone begins to worry about a sleepless two-year-old developing an eating disorder at age 16.

Interestingly, picky eating in early childhood was not correlated with the development of eating disorders late in life (much to the relief of toddler parents everywhere).

If you have a child with an eating disorder, did they suffer from sleep problems as a toddler? Do you think this study's findings have enough merit to be followed up on?


Hafstad, G.S., von Soest, T., Torgersen, L. (2013). Early childhood precursors for eating problems in adolescence: A 15-year longitudinal community study. Journal of Eating Disorders, 1(35).

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Don't Talk to Your Kids About Weight

Tuesday July 16, 2013

Researchers in Minnesota recently published an article in JAMA Pediatrics detailing their findings regarding parental conversations about weight and healthful eating with adolescents, and found that "parent conversations focused on weight/size are associated with increased risk for adolescent disordered eating behaviors, whereas conversations focused on healthful eating are protective against disordered eating behaviors."

The study utilized a large survey, which included an ethnically diverse population of 2348 adolescents and 3528 parents from 20 different middle and high schools in the Minneapolis/St. Paul area.

Specific results showed that among non-overweight adolescents, conversations with mothers about healthful eating (as opposed to weight) were associated with a significantly lower prevalence of dieting.  In addition, the instances of binge eating were less in families in which mothers didn't engage in any conversations about weight or eating.  Among these same adolescents, if fathers spoke about weight, there was a significantly higher prevalence of dieting.

The results for overweight adolescents were similar, although there were no significant correlations between parental conversations and binge eating.  All of these results underscore the importance of parental influence and conversations, even during the turbulent years of adolescence.

This information is both interesting and important for parents today.  There are a range of problems facing children and adolescents in regards to weight and eating including an increased number of eating disorders and issues with obesity.  It can be difficult to know how and if you should approach the topic and how address it in your child's life. This research clearly shows that if you choose to bring up food and weight at all, the focus should be on healthful and balanced eating rather than worrying about weight and/or size.

Did/do your own parents talk about weight?  It might be your weight, their weight or other people's weight.  How does it affect your own views of yourself and food?


Berge, J., MacLehose, R., Loth, K.A., Eisenberg, M., Bucianeri, M.M., Neumark-Sztainer, D. (2013).  Parent conversations about healthful eating and weight. JAMA Pediatrics. Published Online June 24, 2013.

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Do our utensils affect how we perceive our food?

Wednesday June 26, 2013

A new study, from the University of Oxford and published in the journal Flavour, indicates that the size, weight, and color of our cutlery can change how we perceive the taste, density and expensiveness of our food.

Dr Vanessa Harrar and Professor Charles Spence, who performed this study, explain, "How we experience food is a multisensory experience involving taste, feel of the food in our mouths, aroma, and the feasting of our eyes. Even before we put food into our mouths our brains have made a judgment about it, which affects our overall experience."

In the initial experiment, tasters were asked to taste yogurt in five different spoons: two plastic teaspoons (one heavy, one light), two tablespoons (one heavy, one light), and one "fancy" spoon.  Interestingly, results from the "fancy" spoon were not significant.  However, tasters rated yogurt eaten from the heavy spoon as least dense, least expensive and least liked.  However, it was rated the sweetest.  The size of the spoon also affected how sweet the yogurt was perceived, with smaller spoons influencing the taste to be sweeter.

In the second experiment, tasters were asked to taste yogurt on five different colored spoons (red, blue, green, black, and white).  There were two samples of yogurt as well, a typical 'white' yogurt and the same yogurt colored with red food coloring.  Interestingly, tasters rated white yogurt in the blue colored spoons as saltiest, although the authors hypothesize that this is because salty foods are often sold in blue packaging, in the UK.  Black and white spoons had opposite effects on the saltiness ratings of the white and colored yogurts as well.

In the third experiment tasters were asked to sample two types of cheese from a white plastic fork, a knife, a spoon and a toothpick.  The perceived saltiness of the cheese was affected by the utensil used, with cheese eaten from knives being rated as the saltiest.

Although this study doesn't look at the interaction between utensils and eating disorder behaviors, this information is interesting, given the knowledge that many people with anorexia nervosa are known to use specific utensils when eating, sometimes insisting on using smaller, child-sized utensils anytime that they eat.  It may also bring about future research on whether specific colors, sizes or weights of utensils are better (psychologically speaking) for someone who needs to eat more, or eat less.

Have you noticed that your own eating perceptions or habits changes based on what utensils you are using?  Do you have preferences for specific weights or colors?


Harrar, V., & Spence, C. (2013). The taste of cutlery: how the taste of food is affected by the weight, size, shape, and colour of the cutlery used to eat it. Flavour, 2(21). doi:10.1186/2044-7248-2-21

photo courtesy of Elizabeth Willing

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"Fat Talk" May Make You Less Likable

Friday May 10, 2013

Professor Alexandra Corning  and her team in the Department of Psychology at The University of Notre Dame recently presented their research findings at the Midwest Psychological Association on the likability of women who engage in fat talk.

Fat talk is a type self-disparaging speech about weight, food, and/or dieting.  It is often characterized by conversations about what one should or shouldn't be eating, how much someone should or shouldn't be exercising and how they feel about their current size, shape, and/or weight.  Research has shown that this type of talk has  negative consequences including placing people at a higher risk for the development and/or maintenance of eating disorders.

This study utilized 139 undergraduate participants who were of 'normal' or 'average' size.  The participants were shown photographs and quoted statements by women who were noticeably thin and noticeably overweight.  Some of the statements were clearly fat talk, while others contained body affirmations.

The study found that people found the women (both thin and overweight) making positive statements about their bodies to be more likeable than those who were engaging in fat talk.

This research backs up what I have heard from clients who discuss the negative effects of being around people who are negative about their bodies and the positive and supportive relationships they are able to build with people who are body-affirming.

How do you talk about your body?  Even if you don't have an eating disorder, the way you talk may affect those around you and your relationships.  Do you need to work on excluding fat talk from your life?

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