Fasting and Eating Disorders: A Slippery Slope

Monday, September 28, is Yom Kippur, the Day of Atonement. Yom Kippur is considered the most important holiday in the Jewish faith and is typically observed by a day of fasting and religious services.

Every September, as Yom Kippur approaches, I engage in conversations with my Jewish patients and their families about observing this holiday.   Families that are dealing with eating disorders frequently ask me if they, or their child, should fast for Yom Kippur.  I believe strongly that anyone who has an eating disorder, is predisposed to developing an eating disorder, or has a history of an eating disorder, should not fast for any reason.   So my answer, to anyone who falls into these categories, is a resounding NO!

Individuals with illnesses, including those with active eating disorders, are exempted, by Jewish law, from fasting. But what about those who have recovered from eating disorders, or those who are predisposed to eating disorders but have not (yet) developed a full-blown illness? Fasting poses a grave but hidden risk to these individuals as well.

Here’s why: most eating disorders are triggered by a negative energy balance, which is a period of time in which a person is consuming fewer calories than they are expending.  People who are not predisposed to eating disorders may feel uncomfortable, weak, tired, or “hangry” while fasting, will overindulge in food to break the fast, and then will promptly return to their normal eating habits. 

For people who have a genetic predisposition towards eating disorders, regardless of whether the eating disorder is currently active, a negative energy balance often takes a more sinister turn.  These individuals often feel better when they are fasting, and fasting very quickly becomes a self-perpetuating cycle.  The less they eat, the less they want to eat, until it gets to the point that they are not able to bring themselves to eat at all without significant external support.

In our culture, most eating disorders are initially triggered by an intentional negative energy balance such as dieting or a conscious attempt to “eat healthy” (which, sadly, is often a euphemism for dieting).  But some eating disorders, especially in preadolescents and males, are initially triggered by an unintentional energy deficit through illness, dental procedures, athletic training, growth spurts, stress, depression, or religious fasting.  Many people who recover from eating disorders will wisely avoid dieting, but experience relapses nonetheless through unintentional negative energy balances.

People who fast for religious reasons may have no intention of altering their body weight or shape, and may be truly devoted to observing their faith.  But the body doesn’t know the difference.  It simply registers that a negative energy balance is occurring and responds as it is genetically programmed to do.  Once the switch is flipped by a period of negative energy balance, the eating disorder may be set in motion by a cascade of disordered thoughts and behaviors accompanied by increasing difficulty eating.

Some individuals in the Jewish community who have recovered from eating disorders eschew fasting on Yom Kippur and have found other meaningful ways to observe the holiday. For those who are predisposed to eating disorders but want to observe Yom Kippur, I often recommend a different type of fast.  Perhaps a technology fast, such as going 24 hours without a smartphone or without social media.  These types of fasts still convey a sense of deprivation, but without the dangerous possibility of triggering an eating disorder relapse.  In fact, many people find that going without their phone or their social media for a day allows them to be more fully present in the moment and dramatically reduces their stress levels.

The Power of Families

The first World Eating Disorders Action Day (WEDAD) will be held on June 2, 2016.  This is an event that I support with hope and enthusiasm.  Since opening my private practice in 2009, I have been an advocate for, and practitioner of, evidence-based treatments for eating disorders and related mental health conditions.

In my clinical practice, I am consistently awed and inspired by the power of families.  Parents have unique knowledge about their children and unparalleled investment in their children’s long-term well-being.  In addition, parents are full-time witnesses to their children’s moods, behaviors, and eating habits.

It should not come as a surprise, then, that patients are more likely to recover when their parents are actively involved in their treatment.  The scientific evidence base is strongest for Family-Based Treatment (FBT), also known as the Maudsley Approach, which empowers parents to intervene directly to help their child restore a healthy weight, resume normal eating patterns, and return to typical adolescent development.   I have utilized FBT since opening my practice, and the results I have observed are nothing short of astounding.

And yet, in the world of eating disorder treatment, parents continue to be pushed aside and dismissed.   It is common practice for a 14-year-old with Anorexia Nervosa to meet privately with a dietitian as her worried parents (who do the family’s grocery shopping and cooking) remain in the waiting room.  Treatment centers often tout “family involvement” as part of their program, but this may amount to nothing more than a weekend visit during their daughter’s 2-month stay.   The professionals in charge may devise a treatment plan for a teenage patient, but the parents never see the document, let alone participate in creating it.

This is unacceptable in 2016.  We know better.

My clinical practice is based upon the belief that parents should be fully informed and actively involved in their child’s treatment.   I convey to parents that they are the experts on their child, and they are the leaders of their child’s treatment team.  I encourage parents to ask questions, to raise concerns, to speak up when they disagree with something I say.  As an expert in eating disorder treatment, I work as a consultant to the parents on behalf of the child.   My goal, then, is to become obsolete as the family learns to help their child recover and stay well.

There are professionals who see patients weekly as outpatients and professionals who see patients for weeks or months at a time in treatment centers.  Then there are parents who spend a lifetime as guardians of their children’s health.  For decades, the balance of power in eating disorder treatment has rested firmly with the professionals.  As our field advances, I would like to see the balance of power shift towards families.  I would like for families to receive more information, more tools, and more coaching in how to help their loved one thrive.  I would like to witness an era of transparency, accessibility, and open communication in which clinicians present to families the full range of treatment options, explain to families what interventions they use and why, along with evidence supporting them.

In this spirit of parent empowerment and true collaboration between families and clinicians, my colleague, Dr. Tarah Martos, and I are honoring World Eating Disorders Action Day by hosting the first annual South Florida Parent Summit on Eating Disorders.   This event, held at my office in Coral Gables on June 2, will involve psycho-education, information, coaching, and parent-to-parent support.   Our goal is to help parents feel confident and competent to guide their loved one towards full recovery.

Families are intrinsically powerful.  As a psychologist, my job is not to grant power to parents, snatch power from them, or wield power over them.  Rather, my job is to remind parents that they have always held the power to help their children heal, grow, and thrive.  I strive to provide parents with the support, guidance, and information they need to unleash their parental power and use it to fight the eating disorder on behalf of their beloved child.