b. Eating Disorders (blog 2): Definitions, prognosis.

This is the second blog on the topic of eating disorders (ED's).

In my first blog I introduced the subject of ED's.  I explained that ED's are an increasing problem in the world - both in the Western world and the non Western world. Studies have shown that the incidence of ED's has continued to increase over the last few decades - paralleling society's growing obsession with being thin, losing weight, and fear of fat. 

In the decade between 1995 and 2005 the incidence of ED's doubled in both males and females.  In Australia it is currently estimated that one million Australians have an ED.  In the US it is currently estimated that 10 million women and 1 million men have an ED. In non Western countries the numbers are less than Western countries - but those numbers are increasing with globalisation and the spread of the Western cultural 'thin' ideal.

Like many medical conditions, an individual's genetic makeup accounts for the heightened sensitivity of some individuals to develop ED's in the current cultural climate. It has been estimated that 50 − 80% of an ED risk is due to genetic effects.  This is why ED symptoms tend to run in families. For example, the first degree family relatives (parents, siblings or children) of an individual with anorexia nervosa(AN) are eleven times more likely to have AN themselves, and six times more likely to have some disordered eating behaviours.  Relatives of individuals with bulimia nervosa(BN) are greater than four times more likely to develop the illness. 

Eating disorders (ED's) are not chic  or de rigueur  to being cool.  ED's are serious emotional and physical addictions.  They are horrible mental illnesses with the highest mortality (around 20%) of any mental disorder. This is partly because they are not purely a mental illness.  They are also associated with major wide-ranging and serious medical complications, which affect every major organ in the body. 

ED's are not  a 'lifestyle choice'. Individuals suffering with anorexia nervosa are not just 'trying to get attention', and  individuals suffering with bulimia nervosa are not simply 'addicted to food'. ED's are not simply diets gone too far either, although, they often start off as a diet. But, once started, they become self-perpetuating and an individual will lose control of the illness.

ED's are, in fact, not about food.  They are about attempting to manage feelings and attempting to cope with problems in life. In this regard, they are a form of 'maladaptive coping mechanism' response to stress.  They are an attempt to use food intake and weight control to manage emotional conflicts which have little or nothing to do with food or weight. 

ED's are, therefore, an external solution to internal problems.  But they solve nothing.  They will never solve the internal problems.  They will cause more problems and solve none.  They are similar to an alcoholic using alcohol to manage emotional problems. The alcohol may start as a way to cope (a maladaptive coping mechanism as well)  but eventually the alcohol takes control of a genetically susceptible individual - and the 'cure' becomes the 'curse'.  The ED 'addictive illness'  becomes an extremely difficult problem from which to escape.

Some of the underlying issues  associated with ED's include: 

Low self-esteem, depression, anxiety, loneliness, feelings of loss of control, feelings of worthlessness, identity concerns, troubled family and personal relationships, and an inability to cope with emotions - especially difficulty expressing emotions and feelings, a history of being teased or ridiculed based on size or weight, and a history of physical or sexual abuse. 

(Please note that an individual with an ED may have only one or two of the items listed above relevant for their situation - not the entire list.  And, of course, other individuals may have important underlying issues not listed above).  

ED's occur in both men and women, young and old, rich and poor, and all cultural backgrounds.  However, ED's are largely a hidden epidemic.  It has been estimated that 20% of females have an undiagnosed ED, and only only 10% of men and women with ED's receive treatment.  And, even then, only 35% of the people who receive treatment for their ED's get treatment at a specialized facility for ED's.  (Which equates to only 3.5% of people with ED's getting help in a specialized ED facility).

So many people in society are suffering with serious  ED's, but few are receiving the help that they need!  

Why might this be? 

It could be because some sufferers are ashamed of their ED, and the stigma attached to mental illness, and they are therefore embarrassed to seek help from a Psychologist or Psychiatrist.  This is especially true for men, who constitute 10-15% of people with AN or BN.  It is known that men are less likely to seek treatment for ED's - because of the perception that they are women's diseases. 

It could be that the cost of Psychology/Psychiatry sessions are prohibitive for  some sufferers.  

It could be because suffers of an ED have previously tried to overcome the illness, but, having failed in the past,  they have now given up hope that they will ever recover - and so they have stopped trying

. 

Please note that like quitting cigarette smoking, or quitting any addictive habit, for that matter, failure along the way is simply par for the course in being successful  You need to try again. And keep trying.  Each time you will learn more about recovery.   

In fact, success has been defined as: getting up one more time than you fall down. 

So, please don't lose hope.

It could be because some sufferers of ED's  think that the ED is a part of who they are; their identity.  And they currently don't want to 'get well'. They may even like to be very thin, with the illness,  or they may worry that they will become 'fat' if they recover from the ED and stop 'dieting'.  (This is typical 'black and white' thinking in Anorexia nervosa sufferers.  Suffers imagine that there are only two options for their weight: fat or thin.  They often cannot yet see a healthy 'middle ground').

Other sufferers of ED's may worry that they won't be unable to cope with life pressures without the ED - which they may use as a 'coping mechanism (maladaptive as it is).  And, for this reason, some ED sufferers may be not yet ready to 'give up' (recover from) the ED. These individuals are often also in denial as to the seriousness and dangers related to ED's.  

Finally, it could be because some individuals are not aware that they actually have an ED. They may think that, instead of having an 'eating disorder', their eating is simply a little disordered ('atypical' rather than an actual 'ED mental illness').  They may not realise that they have crossed a line into a serious ED. And, for this reason, they may not think it is appropriate, nor necessary, to seek professional help.  They may think that they will waste the time of medical professionals if they incorrectly 'label' themselves with an ED.

Which brings us to a fairly brief discussion about the definitions of  ED's.

I think that any discussion regarding a medical topic must first  begin with a clear definition of the illness.  However, I won't go into too much clinical discussion in this brief blog series about ED's - as the medical discussions about ED's can be found elsewhere:  text-books, other medical sites on line, and so on.  

In my blog series I plan to focus mainly on the cognitive processes involved in ED's, and some of the cognitive changes necessary for recovery, and avoidance of an ED relapse.  It has been estimated that 70% of patients regain weight within 6 months of the onset of ED treatment, and 15-25% of those who regain the weight relapse, usually within 2 years.

So, successful cognitive changes are important to discuss with ED's as they not only increase the chance for recovery from an ED (30% don't regain the weight within that first 6 months of treatment), they also reduce the significant risk of relapse. And, unfortunately, some people suffer from ED's for decades. I am hoping that will not happen to you, or anyone that you are caring for with an ED.

In ED's the medical (clinical features and biological changes) are related more to diagnosing the illness, and keeping the sufferer alive. Obviously crucial.  And, this is why all ED suffers must seek medical care as soon as possible.  ED's have the highest death rate of any mental illness.  Medical care is vitally important.  A health care team will likely become involved.(ie.physician,dietician,psychologist/psychiatrist, social worker)  

Medical management is also often needed to support the effectiveness of 'cognitive therapy' for recovery:

For example, if an individual is grossly malnourished - the brain is much less able to think clearly - to take in what is being said, and remember what is being said.  Nutrition and weight will usually needed to be restored before any sort of cognitive therapy can start - if it is to be effective.

Also, co-morbidities (associated psychological issues) - such as depression, anxiety, drug addictions - may need medical treatment during recovery - in order for cognitive therapy to be effective.  So, if a patient were highly anxious or depressed - antidepressants, or other medications - as discussed with your physician - may be necessary for you to think clearly before you start to learn new ways of coping, and viewing life.

Furthermore, re-feeding can be a complex thing - and there can be serious risks if feeding is done too quickly ('Re-feeding syndrome' - which can happen if an individual is refed, from a state of severe malnutrition, too quickly.  Subsequent electrolyte and chemical imbalances have even led to death).

So, as I have said:  All ED's require professional help.

This blog is a start towards recovery. And I would advise for it to be used in conjunction with a professional health-care team.  I hope to inspire ED sufferers to seek help, and give them an idea of the thought distortions, which need to be corrected, and more positive thinking patterns which are required for recovery from an ED, and to avoid relapse. 

I hope that the lessons I learned during my own recovery from an ED, and as the mother of a daughter who also recovered from an ED - will help and inspire others currently suffering with an ED, or caring for someone who has an ED. 

So, briefly, a quick outline of the medical definitions of ED's:

There are currently three main ED's that are recognised in the 'bible' of Psychiatric medicine- the Diagnostic and Statistical manual of mental Disorders (DSM) - and these are:

(1) - Anorexia nervosa (AN)

(2) - Bulimia nervosa (BN)

(3) - Eating disorder not otherwise specified (EDNOS)

and, included as a provisional category in the DSM-IV is a specific example of EDNOS is - (3a)

(3a) - Binge eating disorder.

Brief descriptions of each of these ED's.

(1) Anorexia nervosa (AN):

Anorexia nervosa is self imposed starvation.

The term 'anorexia'  is of Greek origin: 'an' - meaning 'lack of',  and 'orexis' - meaning 'appetite'.  So 'anorexia' means a 'lack of desire to eat'.

The term 'anorexia' in medicine still refers to 'a loss of appetite'.  This usually leads to weight but it is due to conditions such as: infections - such as viral illness, flu, gastroenteritis; cancer - causing weight loss; depression - such as in a grieving individual who is no longer interested in food.

However, anorexia nervosa (AN) is not due to a lack of appetite - but instead it is due to a strong desire to control the appetite that is the central feature.

So the word 'anorexia' alone is not enough to classify AN - as sufferers of AN long to eat; obsess and dream about it; some of them even break down and eat uncontrollably.

Rather than lose the desire to eat, these sufferers with AN spend 70-85% of each day thinking about food - but denying their body in spite of their hunger.

They often want to eat so badly that they cook and feed others, study menus, read and concoct recipes, and go to bed and wake up thinking about food.

This is the same response to starvation as seen in subjects without AN - starved during psychological experiments, or starved during times of war.  The mind typically fantasises about food endlessly.

Individuals with AN refuse to maintain a normal body weight (defined as 15% below the normal weight for age and height.  Their BMI < 17.5). 

They also have an intense fear of becoming fat and their body image is severely distorted.  They see themselves as being over weight when they are overly thin. And, they tend to deny the seriousness of their low body weight.

Despite the increase in AN over the last few decades, AN is not a new illness, nor is it solely a problem of our current culture.

The case of AN most often cited in medical literature as the first documented case occurred in a 20 year old girl treated in 1686 by Richard Morton and explained in his work 'Phthisiologia: Or a Treatise of Consumptions' (1694) .  He called the condition 'nervous atrophy' or 'nervous consumption'. Morton described the girl as being like a 'skeleton only clad with skin', but having no fever - on the contrary, he wrote,  'her whole body was cold'.

The first case study of AN in which we have descriptive detail from the patient's perspective was a woman - Ellen West (1900 − 1933).  She kept a diary in which she recorded her inner turmoil with the illness. She eventually committed suicide, at the age of 33, to end her desperate struggle with thinness and food.

Even today patients with AN demonstrate the same behaviour - rigid control of their 'out-of-controllness,'  and overwhelming suffering as a result of the mental illness.  Suicide is still one of the leading causes of death associated with ED's.

In the DSM-IV - two sub-types of AN are classified:

(i) - a 'restrictive type': characterised by strict dieting or exercising without binge eating.

(ii) - a 'binge-eating/purging type': characterised by episodes of binge eating and/or purging via self-induced vomiting or misusing laxatives, enemas, or diuretics.

The prevalence of AN is about 1% in adolescence and young women.  Roughly 50% of people with AN may eventually develop bulimia nervosa.

(2) Bulimia Nervosa (BN):

Bulimia nervosa (BN) is characterized by recurrent episodes of binge eating.

Binge eating - is defined as consuming large amounts of food in a discrete period of time (ie. within any 2-hour period) plus a subjective sense of lack of control over eating.

BN is further characterized by regular use of extreme weight control methods - such as vomiting, abuse of laxatives, diet pills, or diuretics; severe dieting or fasting; vigorous exercise.

BN is also associated with dysfunctional attitudes about weight or shape that negatively reflect on self-opinion. 

In the DSM IV - both binge eating and inappropriate weight control methods must have occurred, on average, at least twice per week during the last three months.

In the DSM-IV - two sub-types of BN are classified:

(i) - a 'purging' type (vomiting)

(ii) - a 'non-purging' type - which is limited to severe dieting, fasting, or exercise forms of weight control behaviours.

If either form of BN occurs during a current episode of AN, the assigned diagnosis is AN.

BN is more common in females than AN, and it has an estimated prevalence of 2 − 3% in young females.

(3) Eating Disorder Not Otherwise Specified (EDNOS):

EDNOS is generally considered the most prevalent form or category of ED and the least studied.

Most patients who present for treatment with an eating-related problem have a 'partial syndrome' or EDNOS.  That is, they fail to meet all of the exact diagnostic reuirements of one of the 'formal' ED's (AN or BN) - but they have significant symptoms and associated problems.

It may be that the definitions of AN and BN need to be broadened - which could then include EDNOS in the spectrum of disorders. 

(3a) Binge Eating Disorder (BED):

This is included as a 'provisional category in the DSM-IV.  It is, however, a specific example of EDNOS.

BED is characterised by recurrent episodes of binge eating (an average of two days with binge episodes per week over a six month period is required; marked distress exists because of the binge eating).

The binge eating exists without the compensatory weight control methods that are required for the diagnosis of BN.

Unlike AN and BN,   BED is not uncommon in men.

It is the most frequently seen in adults, with an estimated prevalence of 3% of adults and roughly 8% of obese people.

BED occurs in approximately 30% - 50% of people in 'weight control programs'.  (40% are males).

Note:  The dieting industry is the only business in the world that has a 98% failure rate!

BED is associated with an increased risk for obesity and, therefore, for the plethora of medical problems associated with obesity.

                                         *

Body mass index:

The body mass index (BMI) is a measure of relative size based on the weight (mass) and height of an individual. It is often used to predict health outcomes and it is commonly mentioned in reference to eating disorders.  And for this reason I will briefly define it - while I am in the process of defining things:

BMI = mass (kg) divided by height (meters) squared.

So BMI = wt(kg)/ht squared.

So, if someone weighed 60kg and their height were 1.65 meters:

BMI = 60/(1.65 X 1.65) =  22

BMI = 22

The current recommended healthy BMI range is 18.5 − 25.

A BMI less than 17.5 in adults (over 20 years), or 85% of expected weight, is one of the common physical features in diagnosing Anorexia nervosa.

A BMI from 25 to 30 may indicate that a person is overweight.

And, a BMI from 30 upwards suggests that a person is obese.

Sufferers of Bulimia nervosa (BN) often have greatly fluctuating BMI's ranging from underweight to overweight.  Although, as mentioned, if the BN occurs during a current episode of AN (with BMI < 17.5), the assigned diagnosis is AN.

An interesting fact related to BMI and the unrealistic thin culture in Western culture currently:

- The average woman in the US is 162cm (5ft, 4inches) and weighs 63.5kg (140 pounds).  In contrast the average US model is 180cm (5ft, 11inches) and weighs 53kg (117 pounds).

Average US woman BMI - 24.

Average US model BMI - 16

Definition anorexia nervosa - BMI < 17.5!

Western media has a central role in the etiology (causal effect) of ED's. Studies have shown that (not surprisingly):

- 80% of women who answered a People magazine survey responded that images of women on television and in the movies make them feel insecure.

- Some of the pictures of the models in magazines do not really exist. The pictures are computer-modified compilations of different body parts.

- 25% of Playboy centerfolds met the criteria for anorexia nervosa.

- four out of five US women are dissatisfied with their appearance.

- One in three women and one in four men are on a diet at any given time.

- 81% of ten-year-old girls are afraid of being fat.

- One half of 4th grade girls are on a diet.

- In 1970 the average age a girl started dieting was 14; by 1990 the average age dropped to 8.

Imagine how this all relates to my comment in the first paragraph of this blog entry:

 Studies have shown that the incidence of ED's has continued to increase over the last few decades - paralleling society's growing obsession with being thin, losing weight, and fear of fat. 

Signs and Symptoms of ED's: (common warning signs)

(1) Anorexia Nervosa:

- Is thin, but keeps getting thinner 

(losing 15% or more of ideal body weight.  BMI < 17.5)

- continues to diet or restrict foods even though she is not overweight

- Has a distorted body image - feels fat even when she is thin

- Is preoccupied with food, calories, nutrition, or cooking

- Denies she is hungry

- Exercises obsessively

- Weighs herself frequently

- Complains about feeling bloated or nauseated even when she eats normal - or less than normal - amounts of food

- loses her hair or begins to experience thinning hair

- feels cold even though the temperature is normal of only slightly cool

- Stops menstruating

(2) Bulimia nervosa:

- Engages in binge eating and can't voluntarily stop

- Uses the bathroom frequently after meals

- Reacts to emotional stress by over eating

- Has menstrual irregularities

- Has swollen facial glands, giving her 'chopmunk cheeks'

- Experiences frequent fluctuations in weight

- Cannot voluntarily stop eating

- Is obsessively concerned about weight

- Attempts to adhere to diets, but generally fails

- Feels guilty or ashamed about eating

- Feels out of control

- Has depressed moods

(3) Eating Disorders Not Otherwise Specified: (EDNOS)

Experience variations of both of the above disorders.

Also, can include other eating disorders:

(*) Compulsive overeating:

- Unable to stop eating

- Eat very fast

- Eat when they're not hungry

- Eat only when alone, or

- Eat nearly non-stop throughout the day

- Often over-indulge in sugary foods (in attempt to lift their mood)

- experience withdrawal symptoms - when they don't eat the food they crave

(3a) Binge Eating Disorder: (BED)

- Eat large amounts of food when not physically hungry

- Eats much more rapidly than normal

- Eats until the point of feeling uncomfortably full

- Often eats alone (because of shame or embarassment)

- Has feeling of depression, disgust, or guilt after eating

- Has a history of marked weight fluctuations

** Note: All eating disorders require professional help.

Co-morbidities (associated medical conditions) of ED's:

ED's are often associated with other co-existing disorders (co-morbidities) - and these will usually require treatment along with the ED.

Some of these associated problems include the following:

(1) Depression:

Co-morbid depression occurs in 45% - 86% of individuals who seek help for AN, BN, and BED.

Research shows that the ED usually precedes the onset of the depression and ED's and depression don't have the same underlying genetic vulnerability.

(2) Anxiety:

Studies have shown that around two thirds (64%) of individuals with ED's have anxiety disorders during their lives.

- Obsessive-compulsive disorder (OCD) - occurs in between 10% and 66% (depending on the study) of individuals with ED's (less in BN).

- Social phobia - between 25% and 50% (depending on the study) in both AN and BN sufferers.

- Other forms of anxiety are also common, such as - general anxiety, separation anxiety.

(3) Substance abuse (drug addiction and alcoholism):

Disorders where binging and purging is involved (whether with AN or BN) - are associated with higher levels of substance abuse - in ED sufferers and in their other family members.

It is estimated that 25% of individuals with BN experience alcohol abuse or dependence. 

Some individuals with AN may also use drugs (such as cocaine and methamphetamines) to reduce their appetite.

These co-morbid conditions will need to be managed and treated, along with the ED, by the medical team co-ordinating the recovery of an individual.

Prognosis(Outcomes of treatment for ED's currently):

Studies show that ED's (both AN and BN) are illnesses from which individuals can recover!

Although, you will need to be patient.

Recovery usually takes years.

It is also not yet possible to predict who will be successful - at the onset of treatment.

The best prognostic indicators are:

- early intervention in the illness (so don't delay seeking help!)

- fewer co-morbid psychological problems (avoid alcohol and drugs - my advice!)

- infrequent or no purging behaviour

- supportive family or loved ones (if you don't have this - seek out support and learn to accept and love yourself.  My blogs will focus on this.  Very important to recovery)

Most medical consequences of ED's are reversible:

Although, some conditions may be permanent, including -

- osteoporosis (thinning of the bones, fractures)

- endocrine abnormalities

- ovarian failure (infertility)

- obviously - death.

Recovery from ED's:

- A review of various studies have shown that for ED's (AN and BN):

-  approximately 45 % (AN) and 50% (BN) of patients recover

- approximately 33% (AN) and 30% (BN) of patients improve, and

- approxiamtely 20% (AN and BN) remain ill with the full criteria of symptoms.

With BN - at 10 years only 10% meet the full criteria for the disorder.  So, recover continues to improve with BN in the longer term. 

This later continued recovery  for long term BN sufferers, rather than for long term AN sufferers, may be related to the fact that sufferers of BN are more likely to seek professional help - which implies that they may be more motivated to recover.  

Specifically, it has been recorded that 92% of people with bulimia seeking help said that seeking help was entirely their own choice, whereas, only 19% of people with anorexia seeking help said that they did so entirely of their own choice.

This says, also, two things:

1.  Being motivated to recover from an ED - is hugely important to prognosis and recovery.  Finding a reason to recover - is what I will discuss in subsequent blogs.

2.  Professional help is vitally important to recovery.  Very few people can recover without some help from others.  Please seek out help.  Your local doctor or a friend to help find you professional help - is a good start.

                                        *

In finishing this blog, in my short series of blogs discussing ED's and recovery from them,  I will mention a sad fact:

Sufferers of ED's generally have very low self esteem.

So, to anyone reading this - currently suffering with an ED - we will work on that in subsequent blogs in this series.

Be encouraged by the fact that the brain is quite plastic - which means that you can learn new ways of thinking and with this you will feel different - better.  

And those changes will stay. 

Your confidence will improve.  The world will seem kinder and more lovely.  You will learn to see difficulties in life as challenges which you will be able to overcome and learn from.  Rather than seeing them as insurmountable problems.

I hope that you will recover from the ED, and like someone emerging from a dark and lonely prison cell - the sunshine and warmth of the world and all the lovely opportunities and adventures and discoveries and wonderful times awaiting you in your life - will come into view.  

A lovely journey through life for you.

And, as you recover from your ED illness - you will have acquired skills which will help you cope with other unrelated challenges in the future.

You will emerge stronger.

But, to embark on the journey to recovery - is a choice that only you can make.  You will need to trust me that it is so completely worth the work and the fear, which you may now feel, about letting go of the ED.

Trust me when I tell you - the ED is not your friend.  It is a cancer in your mind which will destroy you.

You will need to trust me when I tell you that life is lovely and wonderful when the ED is gone!  You will be safe.  You will find love and happiness.  It will take time and help from others.  

To give you a little idea of my fun and enjoyable  life now - 30 years after I recovered from my ED (anorexia nervosa and bulimia nervosa - from which I suffered for 4 years until the age of 19):

This was my fun morning today - Good Friday of the Easter long weekend.

I have just returned from a lovely 2 hour hike in the wonderful Belair National Park in Adelaide - South Australia.  

My four children (aged between 5 and 17 - including my 17 year old daughter who has also recovered from an ED), my husband, and I walked along trails in the hills of the park.  We wandered amongst the autumn leaves - golden, red, yellow, orange - which drifted to the ground on each gust of wind - like coloured snow painting the landscape in autumn hues. The deciduous trees along our path were also painted in the same beautiful colours, as was the water along the edge of the lake - which mirrored the world around it.  

The path we walked along was more beautiful than any impressionist master-piece - as ours was the original. Not a cold, lifeless reflection of what we were experiencing - stuck to a wall indoors.  

Our autumn world was accompanied by fragrances of flowers and trees; warm sunshine - which crept between forrest branches and dissolved into the shade beneath; and cool breezes - which shook leaves from trees, moved in shadows across the surface of the lake, and swept through our hair while it invigorated our souls. 

Our world also extended beyond the confines of any frame: from the cool green grass, splashed with white and blue flowers, at our feet; into the peaceful woodland, which wrapped itself around us like a snug blanket; up into the cloudless azure sky - a glorious backdrop to the golden canopy of leaves over our heads.  

Our world was not simply visual, either: the limit of any oil-painting. 

Our world was filled with the sounds of birds, and the cheerful laughter and voices of people enjoying picnics, and children playing, beyond the forrest. 

Our world included us. Our conversations and funny stories. Our joy spending time together; creating memories and sharing our lives. We were an integral part of this natural art-form.  

Our world was filled with excitement, as we scrambled over fallen branches of ancient trees in the dry river-bed, or as we ran down hillsides, or as we scrambled up embankments - enjoyable moments reminiscent of adventures in my childhood. 

On our walk today I managed to live in the moment - like when I was a child. No worries about the future.  No regrets about the past.  Although, I must add that with age and greater wisdom, I have learned that not many things in life are worth worrying about or regretting.  But, that for later in these blogs.  For today, I managed to enjoy the loveliness of the world around me.  Nature.  My family.  Fellow hikers and other families - together enjoying the day. 

And, after our walk, as we sat on the grass under a tree, enjoying our coffee in take-away cups, my husband and I shamefully stole our daughter's hot-dog (we are not proud of that - but in our defence - we were hungry).  We told her, when she returned from exploring the bush and the playground, as 12 year olds tend to do, that her hot dog had unfortunately evaporated in the sun (a little known physics phenomenon - which occasionally happens when hot dog, chips, or donuts are left in the sun and in the vicinity of parents for too long).  We sent her off, with money, to buy another one.  We sat in the sunshine and chatted and laughed … and ignored the time … and we had a lovely time.

No guilt about calories.  No thoughts about weight.  No measuring how many kilometers we walked or calories burned.  No thoughts about how I looked in my walking clothes, or whether I am thin enough, or too fat!

And that is what I mean by freedom.  Freedom to live.  And enjoy life. And stop worrying about things that really don't matter.  Like being 'perfect'.  Or having a 'bikini body'.

Just peaceful enjoyment of my life with people I love, in a country I love, in a life … I love.

And I wish that for you!

Freedom from an illness which is destroying you and imprisoning you - away from the life which is waiting for you.  Beyond the illness.

Your life is not the illness. You are not the illness.  You are worth all the effort that I make to help you.  And you are truly worth any amount of effort that other health care professionals will give to you - if you seek help. 

You are meant to be here - with us - fellow humans in this journey of life.

Don't let the illness tell you otherwise!  Don't let anyone else  tell you otherwise!

Maybe some homework this week:

1.  Write at least five good things about yourself.

Here's a clue.  Write down 3 people you admire - living or dead.

Write down 3 things about these people that you admire (ie. kind, intelligent, helpful, strong etc)

Now look at the list.  These are qualities which you possess.

We tend to see in others qualities which we already possess in ourselves.  People are often the worst judge of themselves.  They can see other people more clearly.  And with an ED - you will judge yourself very poorly, and you may find it hard to think of positive qualities.  This is one way to see your own positive qualities.

Don't list anything about your weight as a positive.  You are not your weight.  That is your body.  You are your soul.  That is the real you.

2.  Another little exercise:

Live in the moment and admire something lovely and beautiful around you.  Even if for only one or two minutes.

Live in the moment. Practice mindfulness No worrying about the past or the future.

Be in the moment.  Touch -  feel the soft fabric of your clothes on you skin, the air around you - warm or cool, the chair under you, or the ground or grass on which you sit.  Listen to nature - birds, the breeze rustling the leaves in the trees, the lapping of ocean waves on the shore - obviously depending on where you are. Smell the aromas or scents around you -  flowers, pine trees in the forrest, the earth at your feet, coffee brewing. 

And find a little beauty in those things.  Even just a little.  The world may feel full of worries about the future, and regret about the past, and it may seem dark and lonely and miserable while you have an ED.  

But, you can let a little sunshine into this world - free from worry - if you take a deep breath and leave your worries at the door (for this time) - and live in the moment.  Just for a short time - to begin with. With practice, try doing this for longer.

Have a lovely week.

Next blog I'll start my specific discussions about recovery.  How to start!

I might even use my newly bought video camera and take it on some of my family's lovely walks around Adelaide.  I'll take you with us (for a few minutes to give you an idea) and show you the beauty of the world which the illness prevents you from enjoying.   I'll show you life away from stupid diets and exercise programs.  I'll show you life away from an ED.  While you recover - you might like to come along and see what I mean about life - away from 'bikini bodies' and 'dieting crap' !  

Life is not a perfect body!  Life is about your soul and your life journey.  

You'll see what I mean as we go.

Be brave and come along for the journey.  At least read and see what I have to say.  Even if you don't feel ready yet to recover.

A little proverb to finish on:

Courage is not the absense of fear,

but rather the judgement that something else is more important than fear.'

Ambrose Redmoon.