Kids who Diet: There’s an App for That, But Shouldn’t Be

WW International, the company formerly known as Weight Watchers, recently launched an app called Kurbo which is designed to help children ages 8-18 to diet and lose weight. The app is marketed as a “health coaching” tool, but a closer look at the company’s website reveals testimonials of children losing weight and dropping BMI points, complete with “before” and “after” photos. In recent years, the words “diet” and “dieting” have been replaced with words like “wellness” and “healthy eating” in popular nomenclature. But more often than not, when people refer to “eating healthy,” they are talking about restricting calories, reducing carbohydrates, and decreasing portion sizes. In other words, dieting in pursuit of weight loss. The brilliant marketing team at Weight Watchers, aware of this cultural shift in nomenclature, re-branded themselves as WW (Wellness that Works) to stay in vogue with their client base: people living in larger bodies.

But make no mistake: Kurbo is a diet app designed to help children lose weight. Although the app is touted as being based on years of scientific research, the very existence of this app defies the best available scientific evidence, which strongly suggests that CHILDREN AND ADOLESCENTS SHOULD NOT DIET.

Why? Let me count the reasons.

  1. Bodies are meant to be diverse in size and shape. The very notion that a child or adolescent should lose weight in order to have an acceptable body flies in the face of genetics and natural size diversity.
  2. Weight loss disrupts crucial physiological processes in the growing bodies of children and adolescents. Puberty requires significant weight gain to ensure proper development of the brain, bones, reproductive organs, and other vital body systems. Losing weight during adolescence can halt puberty, stunt vertical growth, and alter hormone levels.
  3. Dieting is not effective at producing long-term weight loss, but it reliably predicts weight gain and depression. More often than not, dieting leads to weight cycling: losing weight in the short-term but regaining weight and ending up at the same weight, or a higher weight, in the longer-term. Our bodies have evolved to protect us against famine by slowing down metabolic processes when food is scarce (such as, when we are dieting and losing weight) and ramping up hunger signals and cravings, which often leads to overindulgence or binge eating. Weight cycling is associated with negative health outcomes, including increased risk of depression. Individuals who diet frequently experience cycles of shame, guilt, and feelings of failure each time they regain lost weight.
  4. The normalization and glorification of diet culture is harmful and toxic to all children. When a person in a position of authority (e.g., doctor, parent, teacher, coach) tells a child or adolescent to lose weight, or places that child or adolescent on a diet, the message being sent (either subtly or overtly) is: “Your body is not acceptable as it is, and you must work very hard change your body in order to be attractive, healthy, happy, or socially accepted.” This message is damaging to a young person’s self-esteem, confidence, and body image.
  5. Diet culture disproportionately targets and stigmatizes individuals in larger bodies, thus perpetuating weight stigma.
  6. Although dieting itself does not cause eating disorders, dieting (or food restriction of any kind) can trigger the onset of an eating disorder in a child who is genetically vulnerable. Further, diet culture creates a toxic environment for individuals who are recovering from eating disorders. Eating disorders are dangerous, debilitating, difficult to treat illnesses that have the highest mortality rate of any psychiatric disorder.

Thankfully, there are many other individuals and organizations who share my sentiments on this matter and are publicly condemning this app.

  1. Healthcare Providers Against Kurbo. A group of physicians, psychologists, therapists, and dietitians who specialize in treating eating disorders has formed a petition protesting the Kurbo app. You can read and sign the petition here.
  2. Registered Dietitian Christy Harrison published an article in the New York Times explaining why the Kurbo app is harmful to children.
  3. FEAST (Families Empowered and Supporting Treatment for Eating Disorders) posted a position statement condemning this app.
  4. NEDA (National Eating Disorders Association) published a position statement expressing grave concerns about the app.

So, you might ask, if dieting is not the answer, then what should we do about childhood obesity? The answer, based on the best available scientific research, is that obesity per se is not the problem, and thus the pursuit of weight loss per se is not the solution. Instead, adults who are charged with the task of caring for our youth (e.g., parents, teachers, coaches, and doctors) should encourage health-promoting behaviors in children across the weight spectrum. Children of all weights will benefit from eating balanced family meals containing a wide variety of foods from all food groups. Children of all weights benefit from adequate sleep, daily physical activity, and limited screen time. Children of all weights should be taught body acceptance and should be educated about size diversity. This is true health promotion. In some cases, these health-promoting behaviors will result in weight loss for higher-weight children, and in some cases, they will not. But regardless of what happens to the child’s weight, these health-promoting behaviors bring about genuine improvements in the child’s physical and mental well-being. And – this is important – NO HARM IS DONE.

Sorry, WW Kurbo app – you’ve got it all wrong.

After Weight Restoration: Mindfulness for Body Image

There are some people with Anorexia Nervosa (AN) who continue to struggle with significant body dissatisfaction well after their weight has been fully restored and normal eating patterns have been established. For these individuals, mindfulness can be a powerful tool to help them make peace with their bodies.

Jon Kabat-Zinn, creator of the Mindfulness Based Stress Reduction program for treating depression, defines mindfulness as: “the awareness that emerges through paying attention, on purpose, in the present moment, non-judgmentally, to the unfolding of experience moment by moment.”

Although mindfulness has its roots in ancient Buddhist philosophy, it is not a religious practice in itself. Mindfulness can be practiced formally, through mediation, or informally, by learning to be mindful while performing everyday tasks.

Research has demonstrated that mindfulness can reduce the tendency to react emotionally and ruminate on transitory thoughts. It follows, then, that mindfulness – especially with its focus on acceptance and non-judgment – may help people let go of negative thoughts about their bodies.

Yoga, a mindful form of movement with benefits for both physical and mental health, can help alleviate the mental symptoms of eating disorders. A randomized controlled trial of adolescents undergoing treatment for anorexia nervosa, bulimia nervosa, and other eating disorders found that adding yoga to a teen’s treatment plan helped to reduce food preoccupation, body dissatisfaction, and eating disordered thoughts. In recent years, many treatment centers have added yoga to their programs.

I often recommend yoga to my newly weight-restored patients as a means of reconnecting with their bodies, reducing stress, and improving physical fitness. Recovering people frequently enjoy yoga even more than they expected to. As one of my college-aged patients told me: “When I was really sick with Anorexia, I felt like my body was something I had to beat into submission. Now, I feel like my body and I are on the same team.”
That is the essence of yoga – a union of body and mind.

Mindfulness has become very popular in the field of mental health. The newer third wave behavior therapies, including Acceptance and Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT), and Mindfulness-Based Cognitive Therapy (MBCT) all contain a core component of mindfulness. These mindfulness-based treatments have been adapted specifically for targeting body image.

Anyone with a book or a computer can begin practicing mindfulness for body image. It does not require a therapist or other trained professional. There are plenty of self-help books and internet resources on this topic:

ACT For Body Image Dissatisfaction
Living With Your Body and Other Things You Hate
The Free Mindfulness Project

Many of my patients in their late teens and early 20’s find that taking a mindfulness approach to their body image is more helpful than a simple cognitive-behavioral approach. Letting go of the struggle, and accepting their bodies as they are right now, brings a sense of peace and contentment which is quite the opposite of the constant struggle of an eating disorder.

After Weight Restoration: CBT for Body Image

As noted in my previous blog post and the comments that follow, full nutrition and weight restoration will often reduce or eliminate the body image disturbance that plagues so many people with Anorexia Nervosa (AN). This is one of the many reasons why it is essential for AN treatment to require full nutrition and prompt weight restoration.

On the other hand, some people with AN continue to experience intense body dissatisfaction after weight restoration. In these cases, Cognitive-Behavioral Therapy (CBT) can help improve body image and reduce suffering.

In order for CBT to be effective, the patient has to have some motivation to engage in the treatment and some desire to improve her body image. The patient also needs to have the insight to understand that her body itself is not the problem, so changing her body weight or shape is not the solution. Rather, the problem is that she has some negative thoughts, feelings, and behaviors related to her body that cause her to suffer. It is those negative thoughts, feelings, and behaviors that will be the targets for intervention. The insight, motivation, and judgment required for effective body image treatment is yet another reason why this intervention is most effective after full weight restoration.

Many of the CBT-informed interventions for body image are similar to those that are effective in treating anxiety and depression. Consider the following:

Cognitive Restructuring
This involves identifying and challenging distorted automatic thoughts related to one’s body image. Examples of distorted automatic thoughts include: “My thighs are enormous,” “I’m the fattest person in this room,” or “Everyone is staring at me because I’m huge.”

The patient may need some help identifying distorted thoughts because they may seem normal or accurate to her. Once she is able to identify a distorted thought as such, the patient is asked to keep a log of the thoughts as they occur. With the help of the therapist, the patient then learns to identify patterns of distorted thoughts, challenge her own thinking, and generate more rational thoughts to replace the distorted ones.

For example, “Everyone is staring at me because I’m huge” contains distortions of over-generalization and mind-reading. Is EVERYONE really staring at you? No. In a room of 30 people, maybe 2 are looking at you. That isn’t everyone. Do you know for sure that they think you are huge? No, because they didn’t say anything of the sort. Why else might they be looking at you? Maybe they like your shirt.

Exposure and Response Prevention
This involves systematically desensitizing the patient, little by little, to her body image fears for the purpose of improving her quality of life. For example, if the patient loves the beach but can’t bring herself to go because she is ashamed of her body in a bathing suit (this is a frequent scenario in my South Florida-based practice!), the therapist may begin by helping her create a hierarchy or “ladder” of challenges increasing in difficulty. The patient would need to “master” each task before moving on to the next one.

For example:
1.) Go to the beach with your best friend at a time when very few people are there, wearing a shirt and shorts over your swimsuit.
2.) Go to the beach with your best friend at a time when very few people are there, wearing just shorts over your swimsuit.
3.) Go to the beach with your best friend at a time when very few people are there, wearing just a shirt over your swimsuit.
4.) Go to the beach with your best friend at a time when very few people are there, and spend 2 minutes wearing just your swimsuit.
5.) Go to the beach with your best friend at a time when very few people are there, and spend 10 minutes wearing just your swimsuit.
6.) Go to the beach with your best friend at a time when very few people are there, and spend an hour wearing just your swimsuit.
7.) Go to the beach with your best friend when many other people are there, and wear a cover-up.
8.) Go to the beach with your best friend and spend 2 minutes wearing just your swimsuit.
9.) Go to the beach with your best friend when many other people are there, and spend 10 minutes wearing just your swimsuit.
10.) Go to the beach with your best friend when many other people are there, and spend an hour wearing just your swimsuit.
11.) Go to the beach without your best friend and wear a swimsuit the whole time.

Environmental Alterations
Once a patient is able to recognize patterns in her negative body image thoughts, she can choose to focus her attention on people, places, and activities that promote positive thoughts and feelings, while reducing or eliminating the negative influences. For example, if a patient has a friend who engages in a lot of “fat talk,” the patient may be assertive with this friend and ask her to stop talking this way around her, or she may decide to stop spending time with this particular friend and hang out with more supportive friends instead. Likewise, if following fitness Instagram accounts makes the patient feel badly about her body, she may decide to stop following these accounts.

Along these lines, many patients find it helpful to donate their outgrown, tight-fitting, or unflattering clothes to charity. The feeling of tight clothes on the body, or the sight of too-small clothes hanging in the closet, can be very triggering. Most people feel much more confident wearing comfortable, flattering clothes.

Eliminating Body Image Rituals
Some people engage in “body checking” rituals, which may be anything from measuring their wrist circumference with their fingers, grabbing the flesh of their belly, spending excessive time in front of the mirror, or trying on 10 different outfits before finding one that looks “just right.” These types of rituals may reduce anxiety in the short term, but they end up becoming self-perpetuating and increasing body dissatisfaction in the long-term.

CBT for body image can be done with a CBT-oriented therapist who has experience working with eating disorders and body image concerns. In my practice, I sometimes use CBT for body image in weight-restored patients with AN after their family has completed a course of FBT (only if it is needed and requested, of course!). I also use it in patients with Bulimia Nervosa (BN) or Binge Eating Disorder (BED) after eating patterns have been normalized, and with non-eating disordered patients who suffer from anxiety or depression and also happen to have struggles with body image.

However, improving body image does not necessarily require a therapist’s help. A motivated patient may be able to utilize these interventions on her own, or with the help of a parent, using internet resources or a guided self-help workbook. I often recommend Thomas Cash’s The Body Image Workbook, 2nd Edition.

There are other interventions for body image derived from 3rd wave behavioral therapies such as Dialectical Behavior Therapy (DBT) and Acceptance and Commitment Therapy (ACT). These will be the topic of my next post.

After Weight Restoration: What About Body Image?

Body image disturbance is one of the most insidious and painful symptoms of Anorexia Nervosa (AN). In many cases, body dissatisfaction is the last symptom to abate. However, the relationship between body image and recovery from Anorexia Nervosa (AN) is fairly complex. Many individuals with Anorexia Nervosa (AN) do not experience body image problems as a symptom of their illness. Most people with AN, however, do have some degree of body image disturbance which changes in intensity over the course of their illness and recovery.

A recent randomized controlled trial of adolescent AN treatment found that weight and shape concerns did not change significantly over the course of treatment. The authors of the study point out that, on the one hand, these results suggest that weight and shape concerns do not get worse over the course of treatment. This finding may come as a relief to patients who are terrified that they will hate their bodies if they gain weight. The authors conclude that “weight restoration alone is not sufficient to ameliorate the weight and shape concerns characteristic to AN.”

While the authors’ conclusion may be accurate in some cases, my clinical experience with AN patients as well as my knowledge of statistics leads me to a different conclusion. I have observed that the relationship between weight restoration and body image varies dramatically from person to person. When it comes to AN and body image, people tend to fall into one of the following categories:

1.) Those who do not have significant weight or shape concerns.

2.) Those who present for treatment with significant weight and shape concerns, which gradually abate over the course of weight restoration and may even disappear by the end of treatment.

3.) Those who become increasingly dissatisfied and distressed by their weight or shape as they restore weight.

My hypothesis is that the authors of the study found no significant change in body image over the course of treatment because patients in group 2 and group 3 essentially cancelled each other out, while those in group 1 did not impact the results in either direction.

As you can see from the groupings above, body image disturbance may not even be relevant for the patient (group 1), and if it is, weight restoration alone may be sufficient to improve body image (group 2). For this reason, I typically postpone addressing body image until after weight restoration has been accomplished and the patient has re-established normal eating patterns. By postponing body image work until the end of treatment, the patient and her family save a lot of time, money, and stress, as a substantial proportion of patients do not need it.

Individuals in group 3, however, may benefit from working on their body image in therapy. Helping these individuals improve their body image will be the topic of my next blog post.