What is Lobby Day?

The Eating Disorder Coalition sponsors lobby days at the US Congress twice per year.  The next lobby day is in Washington, DC on April 16 and 17.  The full itinerary is available here:

http://eatingdisorderscoalition.org/LobbyDayApril2013.htm

You do not need to be a member of EDC, but members get a reduced rate to participate.  To get a feel for what lobby day is like, the fall 2010 EDC lobby day hearing is available on youtube here: http://www.youtube.com/playlist?list=PLkWdTgyoj0OZlGp83Sf-49Tb5NyaGzs-C

What issues is the EDC currently addressing?

The EDC is currently working on 2 primary issues:  1) Mental Health Parity (helping make sure people get ED treatment covered at parity) and 2) The FREED Act: http://eatingdisorderscoalition.blogspot.com/2011/07/what-is-freed-act.html.

Previous lobbying by the EDC resulted in Congress directing NIH to release an RFA http://grants.nih.gov/grants/guide/rfa-files/RFA-MH-14-030.html for research studies that use dimensional constructs to integrate biology and behavior in the service of advancing the understanding of biological mechanisms and developmental trajectories of eating disorders.

How can you get involved?

Patients and families can attend lobby day or write letters to their congressman and/or call on Lobby Day to add extra support.

Clinicians can attend lobby day or email mmorris@eatingdisorderscoaliton.

Researchers should apply for the RFA to show NIH that these requests are needed

How does Lobby Day work?

The EDC provides training and then takes you to meetings with your representatives. You get to be a lobbyist for a day!  People get to share their personal stories with members of congress.  There is a team leader from EDC there to help you.  Said one participant, “I confess I was nervous the first time – who was I to lobby? Eek! But all you need is comfy shoes and YOUR story: EDC makes it simple.”

Those who participated in the past described lobby day as empowering and uplifting. “The chance to stand with others and speak our own personal story to people in power is transformative.”  It is also a great chance to stand together and make new contacts and friends.

Hold the Date:

If you can’t make it on April 17 hold the date of September 18 for their fall lobby day

By Lauren Muhlheim, Psy.D., CEDS and Kantor & Kantor, LLP

Unbeknownst to most mental health consumers, a change went into effect in January, 2013 that may have far-reaching ramifications for those receiving outpatient psychotherapy.  For the first time in 15 years, changes were made to the coding system used to describe and bill for mental health treatment.   This change has resulted in chaos for many mental health professionals who bill their patients’ insurance.  Nationwide, many mental health providers have reported problems with filing and receiving timely reimbursement for claims filed under the new coding system.

Why were the Current Procedural Terminology (CPT) codes changed?  The Centers for Medicare and Medicaid Services (CMS) establishes the Current Procedural Terminology (CPT) codes that providers use to communicate with insurance companies.  The CPT codes are periodically reviewed in partnership with the American Medical Association (AMA).  For the last several years, the AMA and the American Psychiatric Association (APA) advocated for changes in the codes that would treat (and reimburse psychiatrists) like other physicians.  Psychiatrists have traditionally been on the low rung of physician pay scales.  The changes allow (and now require) psychiatrists to bill separately for the different services they frequently provide in the course of a single session (medical examination, psychotherapy, and medication management).  The hope was that the new codes, in providing more flexibility in session length, would highlight the complexity and diversity of what psychiatrists do.  There are additional “add on” codes for “complexity” as well as for crisis management.  Since all mental health providers use the same psychotherapy codes, non-psychiatrists have had to adopt these as well.

For the majority of recent psychological treatment history, the standard 50- minute therapy session was billed to insurance under the CPT code “90806”, and was officially described as “individual therapy 45-50 min.” In practice, most therapists have scheduled patients on the hour and allocated one hour per patient, spending approximately 50 minutes face to face.  This often stretches to 55 minutes by the time one handles payments and schedules the next appointment and allows a few minutes between clients for notes, bathroom breaks, and checking messages.  In 2013, the 90806 code was eliminated and replaced with several alternatives:

• 90832 – psychotherapy 30 minutes
• 90834 – psychotherapy 45 minutes
• 90837 – psychotherapy 60 minutes

Practitioners were informed about the change in October 2012, but given little specific information on how to use them.  The American Psychiatric Association provided the following interpretation:

Note: Since the new psychotherapy codes are not for a range of time, like the old ones, but for a specific time, the CPT “time rule” applies. If the time is more than half the time of the code (i.e., for 90832 this would be 16 minutes) then that code can be used. For up to 37 minutes you would use the 30 minute code; for 38 to 52 minutes, you would use the 45-minute code, 90834; and for 53 minutes and beyond, you would use 90837, the 60-minute code.

By “time,” the APA means face-to-face time with the client.

So what’s the hitch?  The 50-minute session suddenly no longer exists, and that creates a problem. Many practitioners assume the 45-minute session is the intended replacement for the 50-minute session.  However, they fear that reducing time spent with patients will both reduce treatment efficacy, as well as be used as justification by insurance companies to reduce reimbursement rates.  Remember, reimbursement rates haven’t been raised in 18 years and are typically only half of what a patient would pay if they didn’t have insurance.  The other option, the 60-minute session, makes it harder for therapists to complete paperwork and take bathroom breaks unless they space clients further apart, complicating schedules for everyone involved.  And it’s not even clear whether insurers will choose to cover the 60-minute session.   It appears that some insurers are not.

For psychiatrists, the new codes are extremely complicated. The 2013 Medicare fee schedule reveals that reimbursement for psychiatric evaluations with medical services – those done by psychiatrists – will be lower than reimbursements for psychiatric evaluations done by social workers and psychologists.  “This makes no sense, and seems to run counter to the premise that creating a comprehensive system of coding services would create an appreciation for the complexity of the medical aspects of treating mental disorders, address parity, and decrease the stigma to seeing a psychiatrist.”[1]

The CPT changes have thus far resulted in confusion and delays in processing mental health claims because insurance companies were not prepared, equipped, or organized for this change.   Insurance companies had not yet set rates for the new codes, nor had they decided which codes they would accept.  As a result, claim processing since the first of the year has been slow, impacting patients, therapists, and insurance companies.   Helen Stojic, a spokeswoman for Blue Cross Blue Shield of Michigan told NBC News, “The amount of changes and the work involved was much bigger than … the folks involved anticipated.”[2]

Around the country, mental health providers have reported problems with insurance reimbursement.  Some are reporting financial difficulty due to the delay in cash flow.  The biggest worry, however, is that this coding chaos will affect care for millions of vulnerable patients.

What does this mean for providers? In simple terms, less pay, delayed payment, and financial hardship.  “We are ethically bound not to leave patients hanging,” Steven Perlow, president of the Georgia Psychological Association and a psychologist in private practice said. “I will personally see people for a sliding scale … there have been situations where I’ve seen people for free.”[3] Additionally, providers may experience disincentives to stay on insurance panels.  Lastly, these factors may affect providers’ ability to deliver quality care.

What does this mean for patients? To start with, session lengths could be reduced by 10%, meaning less treatment.  Furthermore, patients may have increased difficulty finding practitioners who are willing to accept insurance. Therapists may very well be waiting to see what is happening with reimbursement rates before accepting more insurance patients, or may leave panels altogether.

These outright denials of payment and system wide delays have caused chaos among providers and their patients, and could last for months.  This disorder and confusion has the potential to jeopardize access to care for millions of mentally ill Americans, who depend upon the stability of treatment from their mental health providers.

Action Plan

If you feel that the 2013 psychotherapy CPT codes have negatively affected how you are able to deliver or receive patient care, let your voice be heard:

• Here is a link to an on-line petition to include insurance companies in anti-trust laws and reimburse providers at fair rates: http://www.change.org/petitions/insurance-companies-congress-reimburse-clinicians-fair-wages-and-include-insurance-companies-in-anti-trust-law
• Contact your congressional representatives and let them know how these changes are negatively affecting patient care.

http://www.realpsychpractice.com/2013-cpt-codes/

Lauren Muhlheim, Psy.D., CEDS

Lauren Muhlheim, Psy.D., CEDS is a psychologist and certified eating disorder specialist practicing in Los Angeles.  She specializes in providing evidence-based psychotherapy for adults and adolescents.  www.laurenmuhlheim.com

About Kantor and Kantor                                                                                                                             

Kantor & Kantor is one of the most experienced and highly respected law firms dealing with the prosecution of claims against insurance companies. If your insurance company has unfairly denied payment for benefits, we can help. Call (800) 446-7529 or log on to www.kantorlaw.net.

Self-monitoring of food intake is a helpful eating disorder recovery tool and a central element of treatment in cognitive behavioral therapy.  Research shows that self-monitoring is associated with a positive treatment outcome.  Many of my clients complain about having to carry unwieldy and obtrusive papers to record their intake.  A few have searched for iPhone apps and unfortunately chosen calorie-counter apps that only increase their preoccupation and eating disordered symptoms.  Now there is a better solution, an app called Recovery Record.  Available through the app store, Recovery Record was developed by an Australian student along with Stanford University.  It offers places to record food intake as well as thoughts, feelings, binges, purges, and urges.  There are supportive messages and reminders are sent if a meal is not logged when expected.  There is no affiliated calorie database.

To read more:  visit Recovery Record

F.E.A.S.T. has produced a great article to help families understand the role of the brain in eating disorders.  This is a must-read.

Puzzling Symptoms:  Eating Disorders and the Brain

Highlights from the International Conference on Eating Disorders 2012

• Meeting and spending time with some of the major family and patient advocates, other FBT providers, and clinicians and researchers from around the world all coming together to improve treatment for patients suffering from eating disorders.
• The opportunity to meet and learn from some of the leading researchers in the area of eating disorders.
• Learning about the most recent and ongoing studies. 

A synopsis of one of my favorite talks below:

Tidbits from Tim Walsh and his group at Columbia:  A New Model for Understanding Anorexia Nervosa and Implications for Treatment

In anorexia, dieting begets weight loss which begets more dieting… why is dieting such a persistent behavior?  Tim Walsh and his group believe that operant conditioning, which is implicated in habit formation, offers an explanation.

In operant conditioning, an action is reinforced and this increases the likelihood that the individual will perform the action again.  Repeatedly reinforced behavior becomes almost automatic.  Stress also promotes habit formation.  And random intermittent reinforcement patterns make behavior even more difficult to extinguish.

According to Walsh, a major reason for the persistence of Anorexia Nervosa is that dieting begins as goal-directed, but becomes habitual.  Dieting is learned, it requires repetition, and becomes almost unconscious over time.  It involves structured behavior.  Initially it is rewarding.  Rewards – such as weight loss and compliments – often become intermittent.  Dieting occurs during times of multiple stresses (adolescence).  It is particularly effective at enhancing self-esteem in girls.  It also becomes a way to deal with negative affect and anxiety which provides additional (negative) reinforcement.

Walsh’s group tested treatments based on this theory.  Exposure (to foods) and response prevention resulted in weight gain and decreased anxiety.  The best predictors of positive outcome:  higher percentage of fat in diet, higher energy density of food, and better variety in diet.  Exposure and response prevention, which confronts eating related fears, provided very successful outcomes.

Both Cognitive Behavioral Therapy and Family Based Therapy (two treatments I provide) utilize exposure.  To read more about exposure, read my post on Exposure in the Treatment of Eating Disorders.

Today’s Los Angeles Times contained an article which highlights Family Based Treatment and Cognitive Behavioral Treatment, two treatments I provide:

Today, doctors and therapists focus on a handful of treatments that have been validated by clinical studies. For teens with anorexia, the first-line treatment is something called family-based therapy, in which parents and siblings work with the patient at home to help restore normal eating habits, said Dr. James Lock, an adolescent psychiatrist at Stanford University who specializes in treating eating disorders. Treating patients at home instead of in a hospital setting is less disruptive to their lives and is thought to promote recovery.

The therapy cures about 40% of patients in three to six months, and another 40% to 50% improve but remain ill, studies have found. The remaining 10% stay the same or get worse.

Researchers are still investigating the best way to treat teens with bulimia. Evidence is mounting in favor of cognitive behavioral therapy, which involves helping individuals change their attitudes and thoughts about food and body image. Studies show that about 40% of people with bulimia will recover after three to six months and another 40% will improve but still struggle with the disease; 20% remain the same or get worse, according to a 2010 review in the journal Minerva Psychiatry.

Full article available here:

Families often ask whether they should proceed with a previously scheduled trip or take a well-deserved “break” during the refeeding process.  We advise that travel during Phase 1 of FBT be avoided if at all possible.  We know several families who have vacationed with a child well along in treatment for anorexia and found their child lost 5 to 10 pounds over the course of a week, erasing months of progress.  Children and young adults with anorexia have difficulty with change; if a child is having difficulty completing meals in the home, it is unlikely that they will be able to do so on vacation, where most meals will be eaten in an unfamiliar setting in the presence of non-family members.

During vacation, parents may be tempted to give in more easily to the anorexic thinking and behaviors because they do not want to upset other diners in a restaurant or because they “don’t want to ruin” the vacation after they’ve invested a lot of money in getting there.  The food may be different than that available at home, or it may be difficult to get the types of foods on which the family has been relying.  Children and young adults with anorexia are inflexible; if the food is different than that to which they are accustomed, they may refuse to eat at all.  Sightseeing often involves a lot of walking, which can burn a lot more calories and require even greater caloric intake to offset.  Many vacations occur in warm climates, where health problems related to malnourishment or dehydration may be magnified.  If families do travel during Phase 1 or Phase 2, they should be cautioned that it may cause a setback and prolong the recovery process.

If due to family emergency or some other reason travel cannot be avoided, then parents and caregivers need to have confidence they can feed the way they have been feeding:  similar foods, meals timed in the same manner, supervision of the child for the duration of each meal, not allowing for any slip-ups such as skipping a snack.  There must be a plan in place for contacting the treatment team, if needed.   Follow our instructions below for preparing for travel and feeding during travel, but proceed with great caution.

Many parents ask about dangling out the promise of a trip as a reward for weight gain.  This is not recommended, because weight gain is hard to predict and does not necessarily occur in a linear fashion.  For this reason, it is better to tie consequences to behaviors (100% meal completion) versus outcome (pounds gained).  It is also unfair to set up a child in recovery to be responsible for the loss of a vacation perhaps at the expense of other children.   It is better to postpone the trip entirely until the child is healthier.

Travel may be attempted late in Phase 2 or preferably not until Phase 3.

Signs that your anorexic is ready for travel:

• Eats most meals and snacks willingly
• Eats a wide variety of foods and does not get upset when there are changes or new foods are presented.
• Can handle eating at restaurants and in public and ”fast food”
• Has handled a shorter overnight trip away successfully
• Comfortable eating in front of others
• Comfortable having others comment to them about how “well they are doing” and has discussed their reaction to this situation with their therapist.
• Not bothered by seeing others eat, or seeing what foods others choose in social situations (being around a lot of people choosing foods with which they are uncomfortable can be a trigger)
• Parents feel empowered to step back in if there is a regression during travel

How to prepare for travel: 

• Set expectations appropriately – expect that even a dormant eating disorder may reemerge in an unfamiliar setting
• The family and treatment team should discuss ahead of time what could happen, when it could happen, and the appropriate response.  Consider writing a contract about expected behaviors and consequences if behaviors cannot be maintained
• Discuss in advance about how to ask others treat an anorexic child, and be aware that you will have to coach well-meaning friends and relatives in how to talk with the child.  This can feel very awkward and even cause friction with relatives, so if the family is not confident they can handle this they should reconsider whether the risk of the trip is justified
• Talk with the child:  how do they feel about travel, being in front of other friends or family, going to restaurants?  Discuss the child’s concerns with the treatment team.  This is a great opportunity to expose other fears, faulty thinking, and worries – and to create plans to combat them.
• Talk to others who will be part of the trip to make sure they understand the plan and can help in handling a difficult situation.
• Before embarking on a long trip, observe how the child copes with a practice mini-vacation (an overnight to a nearby destination, allowing an easy retreat to home if things are not going well)
• Research the cuisine and get menus ahead of time –the treatment team can help adapt the current meal plan to the cuisine at the destination, if this seems necessary
• Before the trip begins, have the child practice eating the type of the cuisine that will be available at the destination
• If travel will involve long car trips, plan out the rest stops and meal locations beforehand.  Pack a cooler with the family’s regular foods for the trip
• Plan airplane and airport meals ahead of time and pack extra snacks in case of delays (remember that liquids are not normally allowed through security)
• If dealing with time changes, discuss with the treatment team how to arrange for this.  It is recommended to maintain consistency in the intervals between meals and snacks despite any changes in time zone
• Set consequences for uneaten meals:  finishing food back in the room with a parent, restriction of activities until all food is eaten, and so on.  The family should discuss a plan with the treatment team and feel confident that they will be able to follow through on the plan. They must not be intimidated by the eating disorder, even if it means making a scene in front of others.
• Buffets may be especially overwhelming to a child with anorexia – parents should consider either eating at restaurants with a menu option or making their child’s plate if a buffet is unavoidable.

How to feed on vacation

• Maintain as consistently as possible the feeding routine established at home.  Keep a regular structure of meals and snacks.  This is the number one priority
• Provide the same supervision for meals as at home
• Follow through on any consequences that have been established, even if it means “ruining the vacation”

Try to remember that putting your child’s recovery first and putting off all nonessential travel until your child is weigh restored will go a long way to improving their chances for a full and faster recovery.  Once they are well, you will be able to better enjoy your vacations.  Much further on in recovery, travel can be a great opportunity to expose him/her to new foods and increased flexibility.

Therese S. Waterhous PhD/LD is owner of Willamette Nutrition Source, LLC in Corvallis OR where she does medical nutrition therapy primarily with people diagnosed with eating disorders. Her doctoral work was in nutrition biochemistry and during her graduate work she completed a fellowship in pediatric nutrition, working with children with special health care needs. During that fellowship she had formal training in interdisciplinary team treatment of chronic illness. She has training in family based treatment of eating disorders and is often asked to coach families in refeeding, to coordinate outpatient teams or to educate other health professionals about eating disorders. She recently co-authored the first practice paper for the academy of nutrition and dietetics on nutrition intervention in eating disorders.

Both cognitive-behavioral therapy and family based treatment, two empirically validated treatments for eating disorders, employ exposure techniques.  Exposure works through the process of habituation, the natural neurologically-based tendency to get used to things to which you are exposed for a long time.   During exposure, habituation occurs as people acclimate to their fear and come to realize that nothing actually dangerous is occurring. Habituation promotes new learning of safety, tolerance of fear feelings, and extinction of the fear avoidance urge. 

In “enhanced” cognitive behavioral therapy for eating disorders (CBT-E; Fairburn, 2008), the individual is exposed to shape and weight by weekly weighing.  Individuals with eating disorders often have significant anxiety around being weighed so the weekly weighing provides exposure.  Some individuals weigh themselves excessively, which serves the purpose of a temporary reduction in anxiety, much as an OCD ritual does.  For these individuals, limiting weighing to once a week exposes them to tolerating the unknown between weighings.  Other individuals avoid weighing themselves at all; for those clients, weekly weighing provides controlled and regular exposure.

In CBT-E, patients are also exposed to feared foods.  Just as clients with phobias construct fear hierarchies, in CBT for an eating disorder, therapist and client make a “forbidden food list.”  The client is instructed to rank the foods they are afraid to eat in order of the degree of reluctance to eating them.  The list is then broken down into 4 groups of increasing difficulty.  Over the next few weeks the client is instructed to start introducing these foods into their diet, starting with the easiest and moving on to the most difficult.  The desensitization to forbidden foods is seen as necessary for recovery.

CBT-E also addresses other types of avoidance; for example, avoiding exposing one’s shape by wearing only loose clothing, or avoiding baring one’s arms.  It also addresses body checking and avoidance– similar to weighing, this can manifest as such extremes as either spending inordinate time in front of mirrors or refusing to look in mirrors at all.

While the mechanisms of treatment in Family Based Treatment (FBT) are not precisely understood, one theory is that FBT may work via exposure (Hildebrandt et. al, 2010).   In FBT, the patient is weighed weekly and the weight is charted to visually track weight gain over time, thus providing exposure to one’s weight.   A specific weight target is usually not given.  This serves the additional purpose of the patients having to tolerate uncertainty about a ceiling weight.

In a course of FBT, parents are instructed to “nourish their children according to their severe state of malnutrition, not according to the wishes of the anorexia.”  Because meals commonly take place 5 to 6 times a day during refeeding, this provides ample opportunity for exposure to food.  Anxiety usually skyrockets as parents take over the serving of food at the beginning of the treatment.  However, over time anxiety around eating reduces and meals become easier.  Because this happens in a naturalistic setting (the home environment instead of an inpatient unit), it is believed that the results generalize even better.  

In FBT, parents are left to choose the pace of the exposure to forbidden foods, whether they start with less challenging foods and move up the hierarchy or whether they go immediately for higher calorie foods which maximize weight gain but initially bring more resistance.   In exposure work, the latter is called “flooding,” and while it raises anxiety more in the short term, it also brings around faster results.

Once forbidden foods are reintroduced, it is important that individuals continue to eat these “scary” foods on a regular basis for a while.  The child does not have to eat these foods every day, but the scary foods have to be given enough that they no longer produce anxiety.   This reduces the fear pathways.  Children and adults who have regained their lost weight but not conquered their forbidden foods are at greater risk of relapse.  A child is not better until they can eat all the foods she or he used to enjoy without anxiety or hesitation.

In FBT parents are also encouraged to confront other eating disordered behaviors, such as wearing baggy clothing, cutting food into tiny pieces, and exercising excessively.  By preventing these behaviors, the family helps their child learn to tolerate the anxiety that is generated when the behaviors are not engaged in and over time, the anxiety decreases.

In both treatments for exposure to work, it must be done repeatedly and consistently.  Exposure work is by nature unpleasant because it generates the fear response and for this reason is often resisted by both parents and patients.  However, it is necessary for successful treatment.

Figuring out how to get your starving child to eat and gain weight is a daunting task. Parents often feel overwhelmed and helpless when starting out on a re-feeding program. It is important to remember that your child is literally more afraid of the food than of dying of starvation. But food is the medicine, and it is your job to save her (or his) life.

Anorexia makes children do things they would never normally do and an escalation of behavior is common when parents start to stand up to the anorexia. In fact, an escalation during the first week, although unpleasant and often scary, is usually a good sign that parents are not giving in to the anorexia. Consistent confrontation of the anorexia ultimately brings greater compliance as well as weight gain. It is imperative that parents work together and are well aligned; otherwise the anorexia can split them and gain strength.

Below are excerpts of emails from a family that used FBT:

First weekend:

I will not be able to attend the afternoon seminar. Daughter refused to eat the breakfast and just stormed to her room. As a result, she will not be able to attend her weekend volunteer activity (she volunteers at the Children’s hospital). I feel bad as it is a positive activity for the community. That said, it is the point that it is something that she wants to do. I cannot leave the house as I cannot predict her behavior. Husband will not be able to manage as effectively as I will and plus there will be 4 of sister’s friends over getting ready for a party. Husband and I had plans for a wine tasting tonight and daughter was supposed to babysit younger sister. I know that this will not happen given the rageful reaction.

I am holding strong. Was able to even ignore and work through last night’s outburst of “go f— yourself.” It is like you said yesterday -all of this is so incongruent with daughter’s previous behavior and overall disposition.

After about one week:

Let me first say that I am sold on FBT. I am amazed at just the difference a few days make. Her anger has decreased and she is beginning to manage previously uncomfortable levels of food. I am gradually increasing amounts as well as beginning to include her few taboo items. There is a fine balance to be struck with regard to flooding vs drowning. Husband or I have been going to school for lunch this week. The first time she was utterly pissed – the second time, she accepted. The comments are still there, but a bit decreased and even she has noticed that her anxiety has lessened. In one particularly rational moment, she commented that she wished that we would have done this sooner. I’ll be pleased when this type of thinking is the norm rather than the exception.

It is common for the anorexia, once threatened, to cause children to become angry, hostile, and threatening, and even to blame YOU for ruining their life (by requiring that they eat!). Remember: it is the anorexia that is threatening to kill them and ruin their life, not the food. Do not believe for a moment that you are doing anything awful to your child by helping her to do a basic task that she cannot do for herself. You are taking on the anorexia and that is making the anorexia angry.

One skill that I teach clients who binge eat and overeat is mindful eating.  Mindfulness is a Buddhist principle that involves being fully aware of what is going on both inside yourself and in your environment at the moment.  Mindfulness is a skill that anyone can develop.

Mindful eating – bringing one’s full attention to the process of eating –includes an appreciation for the source of the food as well as attention to the colors, textures, smells, and tastes.  It involves eliminating distractions such as television and paying closer attention to internal sensations.  By eating more slowly and paying attention to what we are eating, we are more likely to notice satiety earlier and less likely to overeat.  Mindfulness also helps individuals to distinguish between emotional and physical hunger.

Several studies have shown that mindful eating strategies can help with disordered eating and possibly help with weight loss.

A basic mindful eating exercise involves eating a grape with full attention to the process:

First, examine the grape in your hand as if you are a child who has never seen a grape.  Notice the color and texture and how it feels in your hand. 

Then take a moment and think about where the grape came from.  It didn’t just fall from the sky and land in your hand.  From the time it was a tiny grape seed, people were involved in tending to this grape.  There was soil and sun and water that helped the grape grow.  There were farmers who took care of it and eventually picked it.  Then it was packed up and truckers took it to the supermarket.  All of these people involved in this grape also were nourished and cared for by other people.  Be aware of the life energy of all the people who contributed to the life of this grape.  Maybe you have other associations to this grape. 

Now, notice what your mind is thinking… whether it is eager to eat the grape or not.   Slowly put the grape in your mouth and notice how it feels in terms of the shape and texture.  Slowly chew on it and be aware of the sensations in your mouth, how it feels on your tongue and how your tongue moves it around.  Slowly swallow and be aware of how that feels.  Notice how you are feeling and whether you are wanting another one. 

Strategies to learn and practice mindfulness:

• Turn off the television
• Set up a relaxing and inviting dining environment with nice plates, flowers, and candles
• Practice eating one meal per week mindfully
• Practice eating mindfully and silently for the first 5 minutes of every meal
• Try eating with your non-dominant hand or with chopsticks
• Put down your fork and take sips of water between bites
• Take small bites and try to chew each bite 15 to 30 times before swallowing
• Set an alarm to go off every 5 minutes during your meal and take a moment of mindfulness whenever you hear the alarm
• Growing your own vegetables and herbs increases your connection with food

Remember that mindful eating is a skill that takes practice.

To learn more about mindfulness:

Mindful Eating by Jan Chozen Bays, MD (2009)

“Mindful eating as food for thought”, New York Times, February 8, 2012