The document discusses evidence that eating disorders can be considered addictions based on criteria for substance dependency from the DSM-V and APA. It notes many similarities between the symptoms of eating disorders and the seven criteria for substance dependency/addiction. The document also discusses research showing deficits in dopamine levels and receptors in the brains of those with eating disorders and addictions, suggesting underlying biological similarities.

1. recovery
Marty Lerner PhD
Defining the Problem and Finding the Solution
eating disorder
A Guide To

2. Acknowledgments
No program, set of ideas, or distillation of knowledge is possible
without the collective energy and contributions of many. The
compilation of experiences and concepts incorporated within
this book is certainly no exception. Were it not for the generous
contributions and dedication of the people who have worked
at Milestones, as well as, those who remain here, this program,
book, and continuing legacy would not exist. It truly does take
the proverbial “village” to make it all happen.
I would be remiss if I did not give a special thanks to myfamily,
especially my wife, Michele. I suspect I could, and perhaps
should, fill the pages of another book about her patience,love,
support, and, did I mention patience, with me. Aside from being
an inspiration and the love of my life, Michele has taught me
more than anyone else about recovery and getting through the
good and bad times together.
Of course my daughters, Janelle and Danielle are not to be
excluded, they constantly teach me about the value of
tolerance, patience, and unconditional love. I suspect our
children are the legacy we leave behind when all is said and
done.

3. And, there’s Reggie – the official service dog of Milestones.
Without his bouncing around the halls and group room, Milestones
would not be the same. Actually, a unique thank you is due to all
of our dogs – since just about everyone on the Milestones staff has
a canine member of the family. Biscuits for everyone

4. FORWARD
Over the course of several years, probably more than I’d like to
admit, the professional community has become split as to how to
view, let alone treat, most eating disorders. If we distill the basic
essence of the division, it would come down to those who viewan
eating disorder as a mental illness and those who look at these
disorders as an addictive disease. What follows comes from the
latter camp. It is the intention of this book to provide both
anecdotal and empirical evidence to support the notion that most
eating disorders fit the accepted criteria common to an addictive
disease. Doing so has significant implications for successful
treatment.
The first section of this book addresses the addiction thesis. In
doing so, reference is made to the American Psychiatric
Association’s most recent description of addiction, as well as, the
criteria it utilizes to diagnose an addictive disorder. This allows the
reader to decide for her, or himself, whether the proverbial shoe
fits. I’ve also added a few articles to provoke additional thoughts
on the matter. As with most addictions, in the end the “addict”
must be able to make the diagnosis him/herself in order to begin
the process of recovery. Doing otherwise does little more than
provide an intellectual framework to further the symptom of
denial.

5. The second section begins to explore the commonality of eating
disorders and attempts to debunk the belief eating disorders
represent separate and different disease entities. The common
thread existing among the various flavors of eating disorders is
reviewed and the trap of focusing on weight, appearance, and
dieting is exposed. Setting the stage for treatment thus begins with
defining the problem.
The third section begins to look at the recovery process at
Milestones. By distilling the basic elements of long-term recovery,
participants in the program learn about, and most importantly
practice, a set of skills that virtually guarantees freedom from
addictive relationships with their eating disorder. In doing so, “one
day at a time” the physical, emotional, and spiritual symptoms
inherent with an addiction begin to change course and recovery
follows.
The fourth section focuses on maintaining your recovery and how
S.E.R.F (Spirituality, Exercise, Rest and Food Plan) can assistyou.
The fifth section of this book is devoted to continuing care and the
role of support groups such as OA [Overeaters Anonymous],
Anorexics and Bulimics Anonymous [ABA], Alcoholics Anonymous
[AA], Narcotics Anonymous [NA], etc. can help you maintain your
recovery.

6. The last section addresses insurance concerns with regard to
treatment and the types of questions you should ask any
treatment center before deciding to attend their program. I have
also included several “abstinent” recipes in this final section.
I hope you find this book helpful in your search forrecovery.
Marty Lerner, Ph.D.
Milestones in Recovery, Inc.
© Marty Lerner, Ph.D. May, 2015
All rights reserved. No part of this publication may be
Reproduced without the author’s permission.

7. Table of Contents
Chapter 1 – The Addiction Thesis for EatingDisorders
Eating Disorders – Addictive or Psychiatric Illness - 1
Table 1.0-Diagnostic Criteria for SubstanceDependency
APA Guideline - 3
Dopamine – the “Feel Good Brain Chemical “– 8
Dopamine, Brain Chemistry and Anorexia – 11
The Case for Commercial Food Addiction – Bloomberg –13
Closing Thoughts – Nature of the Beast- 24
Chapter 2 – Common Denominators in EatingDisorders
Defining the Problem – 29
“If it Walks Like a Duck” – 31
Table 2.1 Similarities among Eating Disorders- 35
Co-existing Addictions and Related Problems – 37
Table 4.1 – The Addiction Pyramid – 39
Table 4.2 – Dual Diagnoses Associated with
Eating Disorders – 42
Cross Addiction and Co-existing Issues – 43
Body Image and Body Dysmorphic Disorder – 43

8. Internal/External Cues: What makes us Different?- 47
My Friend Harry- 49
The Restricting Side of the ED Coin – 51
And the Good News – Long-term recovery is possible – 53
What Comes First – It’s the Egg – 54
Chapter 3 – Recovering from an EatingDisorder
The Roadmap –
When all Else Fails, Follow the Directions – 57
A Word about Therapy - 58
What Works and What Doesn’t Work - 58
Therapy or Therapeutic Setting- 61
The Secret to Recovery- 64
Living in the Solution: The Hard Work – 66
Principles of Constructive Living- 67
And for the Perfectionist-71
Triggers and the Paula Goldberg Theory- 72
So What, Now What – Move a Muscle, Change a Thought-77
Table 3.1 “Behavior First – 79
In Other Words – Easy does it, but do It! -79

9. Control Issues – 83
The Foundation of Recovery – S.E.R.F. – Page85
It’s All About the Food – Isn’t it? - 88
To Weigh or Not to Weigh, That is the Question-90
Measuring Recovery- How am I Doing?-92
Chapter 4: Maintaining your Recovery
SERF Lessons- 95
Spirituality – Give me an “S”- 95
An Exercise in Futility – Give me an “E” – 98
Rest, the Balance between work and play-
Give me an “R”- 100
Food Plans: Food for Thought – Give me an “F” – 103
Basic Tenets of a Recovery Food Plan – 106
Healthy Relationships – The 4 A’s – 109
Relationships in Recovery – “Rules of the Road” – 112
Compliance vs Acceptance – 114
The Transition Home – 119
Summary – 120

10. Chapter 5: Continuing Care after Treatment
12 Step Groups and On-Going Recovery – 124
Open Letter for OA Text – 127
S.M.A.R.T. Recovery – An Alternative or Add on to
12 Step Programs – 132
Continuing Care Resources – 138
Chapter 6: Additional Information
Understanding Insurance for treatment – 141
Abstinent Recipes- 145

11. Chapter One
The Addiction Thesis for Eating Disorders
"What we see depends mainly on what we lookfor."
- Sir John Lubbock

13. 1
Eating Disorders – Addictive or PsychiatricIllness
The committee of the American Psychiatric Association assigned
the task of defining the criteria for chemical dependency, recently
extended these to include all substance dependencies*. It goes
further to recommend a minimum of three of the seven criteria be
met to justify the diagnosis of dependency. * See Table 1.0 APA
Criteria for Dependency
When we examine an eating disorder from an addictions
perspective, the criteria seems to fit equally well. Although some
would argue that food is not an addictive substance, that debate
goes beyond the scope of this chapter for the moment. The point
is both substances and behaviors are capable of emerging as
addictions. Some of us in the professional community have come
to delineate between substance dependency and addictive
patterns of behavior by coining the term “process addictions” for
the latter. As far as I’m concerned, “a rose is a rose” no matter
what you care to name it.
Perhaps the following quote from the American Society of
Addiction Medicine’s task force on addiction best summarizes the
true nature of addiction, and in effect, an eating disorder.

14. 2
“Addiction is a primary, chronic disease of brain reward,
motivation, memory and related circuitry. Dysfunction in these
circuits leads to characteristic biological, psychological, social and
spiritual manifestations. This is reflected in the individual pursuing
reward and/or relief by substance use and other behaviors. The
addiction is characterized by impairment in behavioral control,
craving, inability to consistently abstain, and diminished
recognition of significant problems with one’s behaviors and
interpersonal relationships. Like other chronic diseases, addiction
involves cycles of relapse and remission. Without treatment or
engagement in recovery activities, addiction is progressive and can
result in disability or premature death.” *American Society of
Addiction Medicine, 2012
To see if “the shoe fits”, you might take the quote above and simply
insert the phrase eating disorders in lieu of the word addiction.
Likewise, the words restricting, purging, binge eating, and so forth
could be inserted. In my professional experience, the shoe fits
quite well. It may be time to look at an eating disorder with respect
to its’ real nature rather than surface appearances. The
implications for treatment and long-term recovery areprofound.
Let’s take a moment and review the seven criteria the APA lists as
symptomatic of dependency [aka addiction]. I’ve added a few
comments for each criterion relating it to an eating disorder.

15. 3
Table 1.0
DSM V: Diagnostic Criteriafor Substance Use Disorders*
1 – Tolerance (marked increase in tolerance amount; marked
decrease in effect)
Anorexia – need for continued weight loss or restriction of
caloric intake to experience same effect and avoid negative
emotional state. Bulimia and Binge Eating Disorder – need for
increased frequency and amount to achieve the same physical
/ emotional effect.
2 – Characteristic withdrawal symptoms; substance taken to
relieve withdrawal
In many instances, perhaps not as "dramatic" as drug
withdrawal, the phenomenon of craving, as well as symptoms
of irritability, loss of concentration, headaches, and a variety
of other physical symptoms similar to hypoglycemia and
alcohol withdrawal, may be experienced. Depression and
anxiety are common effects of withdrawal from binge eating and
bulimia. Weight restoration is often associated with short-term
anxiety and depressed mood among those suffering with
anorexia.

16. 4
3– Substance taken in larger amounts and for longer periods
thanintended
Anorexia - decreased body weight is never enough – continued
pursuit of thinness persists despite achievement of weight
goals.
Bulimia and Binge Eating – “I’ll quit tomorrow” phenomenon or
continuing with binge eating and/or purging much longer than
planned, resulting in missed work or social obligations.
4– Persistent desire or repeated unsuccessful attempts to quit
Bulimia and Binge Eating – attempts to stop may include
restricting in order to avoid binge eating or “the need to undo
damage” with purging. Anorexia - intending to increase intake,
but too fearful or unable to judge adequate amount. Repeated
attempts to restore weight marked by repeated periods of
relapse.
5– Increased time/activity/energy spent to obtain, use, and
recover
Common to all eating disorders – time, money, energy to
sustain eating disordered behaviors and increased time needed
to recover from effects

17. 5
6– Social, occupational or recreational activities given up or
reduced
Common to all eating disorders – social isolation, as well
as, diminished activities that interfere with eating disordered
patterns.
7 – Use continues despite knowledge of adverse
consequences (e.g., failure to fulfill role obligations, uses when
potentiallyphysicallyhazardous)
Common to all eating disorders – continued eating
disordered behaviors, despite physical, emotional, social, o r
financial consequences.
*DSM IV R- American Psychiatric Association/American Society of
AddictionMedicine
*Meeting a minimum of three criteria is sufficient for a diagnosis
of substance dependency [DSM IV-R]. DSM V-now defines a
substance use disorder with three subtypes: mild, moderate, or
severe. See: DSM V SUBSTANCE USECRITERIA
In recent years the addiction model, at least as it applies to bulimia,
binge eating, and anorexia has been the subject of an expansive

18. 6
body of research. A terrific summary of this appears in the newly
published text “Food and Addiction” edited by Kelly Brownell and
Mark Gold, Oxford University Press, 2012. The concentration of
this effort has ranged from an exploration of the nature of certain
properties of [mostly refined] foods to the neurobiology and
physiology of [eating disorders] addiction. There appears to be an
interaction between the nature of the substance [addicting or non-
addicting] and the nature of the person [addict or non-addict].
Hence, it is difficult to pin the blame only on the substance without
consideration of the person. For example, morphine is quite
addictive but not all patients receiving this drug to control pain
become “addicts.” Still others, who have a history of addiction, are
more vulnerable to becoming dependent on the drug. We know
today sugar and its’ many derivatives is addicting as a substance.
However, addiction to sugar is both dose and length of exposure
dependent, as well as, being influenced by the person consuming
it. This is to say it takes “two to tango” - with the substance needing
to interact with a predisposed and willingsubject.
The most compelling evidence to date seems to have come to light
with the brain mapping capabilities of modern radiographic
imaging (PET Scan/brain imaging). Sparing the reader the technical
side of this, researchers have been able to locate and display areas
of the brain reacting to substances and stimuli in ways that
differentiate the addict from the non-addict. Furthermore, we now

19. 7
better understand the “reward system” in the brain. We can clearly
see differences between dependent and non-dependent subjects.
Dopamine has been shown to be a primary “feel good” chemical in
the brain. Researchers have uncovered a stunning similarity
between chronic cocaine and stimulant abusers, and compulsive
eaters and bulimics – namely all have shown deficits in dopamine
concentrations and dopamine receptors on their PET scans. The
control subjects [non-addicts] did not display the same deficits. In
yet another study, the two groups were exposed to just pictures of
cocaine or, for overeaters, highly palatable desserts. The visual
cues alone caused a marked increase in dopamine activity among
the cocaine and ED subjects, but not so with their non-addict
peers. So, both an external cue [visual], as well as, the actual
consumption of the substance can elicit changes in brain
chemistry. This is what behaviorists call classical conditioning.
I’ve included an article I wrote summarizing the chemistry involved
with many eating disorders. The focus of the article looks at the
role of one of the basic neurotransmitters we spoke about –
dopamine. As mentioned, dopamine has been studied with respect
to its role in addiction. The progression from use, to abuse, to
dependency likely involves the interplay of amount, duration, and
individual predisposition – whether we speak of a drug or an eating
disorder.

20. 8
Dopamine- the “Feel Good Brain Chemical”*
In an article on the role of dopamine and dopamine receptors from
a March 2010 edition of "Neuroscience" - a well-known and
respected professional journal, the researchers found a significant
difference between laboratory animals that were "over-fed" and
exposed to unlimited amounts of sugar laden and highly processed
[junk] foods versus controls fed regular rat chow. Indeed, the junk
food rats developed an "addiction-like reward deficit" with
dopamine concentrations. The virtual destruction of D2dopamine
receptors in the brain accounts for this.
Translation - over time, when overeating highly "palatable" foods
(e.g. sugar, high fat) they [rats] developed deficits in their ability to
properly assimilate the neurotransmitter dopamine. Deficits in
dopamine are seen with cocaine addicts when they are "crashing"
and withdrawing from cocaine - they become depressed and their
appetite becomes almost insatiable. Likewise, the deficit in
dopamine for binge eaters and bulimics tends to increase over
time with the result being a biological (addictive) propensity to
repeat episodes of disordered eating with greater frequency. Of
course we’ve come to know this phenomenon as tolerance. For the
bulimic, the misguided attempt to deal with this is purging or
alternating between periods of binge eating and restricting, for the
compulsive overeater, controlling this addictive cycle gives way to

21. 9
another "diet". Whether this mechanism plays a role with forms of
anorexia is still a subject for speculation. I suspect the addictive
process with restricting is similar.
Much like the cocaine user who becomes an abuser and then an
addict, neurotransmitters (dopamine receptors) are eventually
destroyed. The only relief is...more cocaine for the fewer receptors
available. The phenomenon of tolerance takes hold and theaddict
needs more of the substance to achieve the desired effect until no
matter how much substance is available it no longer works as it did
in the beginning stages. In fact, in most end stage addictions the
best one can hope for is to postpone withdrawal symptoms.
Addiction thus becomes a full-time career.
The "food addict" may begin abusing food and develops a similar
"tolerance" to refined carbohydrates (sugar, flour) or greater
volumes of food and, likewise, alters the brain's (reward) structure
(dopamine receptors) and the physical addiction to overeating
takes hold. A similar mechanism exists with purging, as applied to
endorphin metabolism. With anorexia the starvation process
creates a sort of tolerance as the body fights to survive and the
anorexic must restrict more and more to maintain the sameeffect
[e.g. avoid weight gain and control despair and anxiety]. Thereare
a few studies to suggest the stress hormone cortisol plays a rolein
this process much like the neurotransmitters in the brain.

22. 11
As with cocaine addicts, it's likely that over any extended period of
time, the mechanisms responsible for manufacturing and making
available dopamine at normal levels will re-emerge... provided the
"addict" adheres to a prescribed course of treatment (e.g. abstains
from the offending substance - cocaine or, for the food addict, the
combination of high-glycemic foods and over feeding [exorbitant
volume]. Likewise, proper nutrition and restoration of a
reasonable BMI would likely have a similar effect for the restricting
forms of eating disorders.
The first step in recovery is recognizing the importance of
abstaining from the offending substance[s] and behavior[s]. Those
with an eating disorder may need to consider a food plan that does
not evoke a physical craving. The current body of research suggests
the more highly processed a food substance is the more likely it is
to heighten the potential for abuse and dependency. The
exponential increase with childhood obesity and early onset
diabetes is directly related to this phenomenon. The evidence has
become overwhelming.
References:
Marty Lerner, PhD .2012
http://www.selfgrowth.com/experts/marty-lerner-phd
Laboratory of Behavioral and Molecular Neuroscience, Dept. of
Molecular Therapeutics
- Published 3/2010 in Nature Neurosciences
Neuroanatomy of Addiction, George Koob, 2012 in Food and
Addiction by Brownell and Gold, Oxford Press, 2012

23. 10
Dopamine, Brain Chemistry, and Anorexia
While we’re touching on the subject of the anorexic side of the
coin, I thought I might add some of the more recent thinking about
the role of brain chemistry and anorexia. There is a divergent group
of brain imaging folks who believe dopamine also plays a role in
disrupting the experience of hunger and appetite with those who
restrict.
There are basically two theories on the table today. The first
suggests overeating types of eating disorders involve dopamine
serving as the “reward” and feel good chemical released when
overeating. However, with the restricting forms of eating disorders
such as anorexia, the experience of increased dopamine
concentrations when eating is unpleasant. Hence, the feelings
associated with eating are negative for someone with anorexia and
rewarding for someone with compulsive overeating orbulimia.
Another group of scientists are looking into the effects of fasting
or restricting on dopamine levels for anorexics - the idea being a
similar surge of “feel good” dopamine, but this time stimulatedby
restricting to the point of starving. In other words, there may be a
phenomenon for some people to “feel rewarded” by severely
restricting their calorie intake. Accordingly, the more one restricts,
at least in the early stages of anorexia, the more dopamine is

24. 12
released, the more rewarded they are, and the more reinforced
restricting behavior becomes. No one knows why some are prone
to this end of the eating disorder spectrum as opposed to the
other. In sum, this hypothesis suggests that dopamine “rushes”
affect anorexics and overeaters alike, but for one group starving
releases the chemical and for the other binge eating does the trick.
Here is an excerpt from Walter H. Kaye, M.D., one of the
researchers at the University of California, San Diego who is
looking into the above theories. His comments also touch upon a
possible explanation for the body image distortions inherent with
anorexia.
“The reason (anorexics) can go on a diet and lose all weight is that
their brain is not responding in a way that is driving eating.”
Whether it’s not responding to the sensory aspect, it is not the
right signal about food, or it’s not rewarding, we don’t really
understand, but there’s something different about these
homeostatic mechanisms.”
“The area of the brain known as the insula, is important for
appetite regulation and also for something called interceptive
awareness, which is the ability to perceive signals from the body
like touch, pain, and hunger. It’s possible that some of the
problems anorexics have regarding body image distortion can be

25. 13
related to alterations of interceptive awareness. There may be
some disregulation of insula function. This may, in part, explain
why a recovering anorexic can draw a self-portrait of their body
image that is typically 3 times its actual size.” To quote from
someone with this experience who is now recovering, “I was down
to 80 pounds at five-foot six,” she says. “My self-portrait was so
distorted I was able to lie down inside the drawing, but that’s how
I saw myself."
A reprint from an article published in Bloomberg News serves as
an excellent summary of the evidence pertaining to the addictive
nature of highly processed [junk] foods. Written by investigative
journalists Robert Langreth and Duane Stanford, the article
explores the social, economic, and biological impact of food
addiction and provides a rather convincing indictment of the
companies profiting from these products. Here is a [reprint] of the
Bloomberg article
The Case for Commercial FoodAddiction
REPRINT- Bloomberg News, April 2011
Robert Langreth and Duane Stanford, investigativereporters
A growing body of medical research at leading universities and
government laboratories suggests that processed foods and sugary

26. 14
drinks made by the likes of PepsiCo Inc. and Kraft Foods Inc. (KFT)
aren’t simply unhealthy, they can hijack the brain in ways that
resemble addictions to cocaine, nicotine and other drugs. “The
data is so overwhelming the field has to accept it,” said Nora
Volkow, Director of the National Institute on Drug Abuse.
“We are finding a tremendous overlap between drugs in the brain
and food in the brain.”
The idea that food may be addictive was barely on scientists’ radar
a decade ago. Now the field is heating up. Lab studies have found
sugary drinks and fatty foods can produce addictive behavior in
animals.
Brain scans of obese people and compulsive eaters, meanwhile,
reveal disturbances in brain reward circuits similar to those
experienced by drug abusers. Twenty-eight scientific studies and
papers on food addiction have been published this year, according
to a National Library of Medicine database. As the evidence
expands, the science of addiction could become a game changer
for the $1 trillion food and beverageindustries.
If fatty foods, snacks, and drinks sweetened with sugar and high
fructose corn syrup are proven to be addictive, food companies
may face the most drawn-out consumer safety battle since the

27. 15
anti-smoking movement took on the tobacco industry a generation
ago.
‘Fun-for-You’
“This could change the legal landscape,” said Kelly Brownell,
director of Yale University’s Rudd Center for Food Policy & Obesity
and a proponent of anti-obesity regulation. “People knew for a
long time cigarettes were killing people, but it was only later they
learned about nicotine and the intentional manipulation of it.”
Food company executives and lobbyists are quick to counter that
nothing has been proven with what PepsiCo Chief Executive Officer
Indra Nooyi calls “fun-for-you” foods, if eaten in moderation. In
fact, the companies say they’re making big strides toward offering
consumers a wide range of healthier snacking options. Nooyi, for
one, is as well known for calling attention to PepsiCo’s progress
offering healthier fare as she is for driving sales. Coca-Cola Co.
(KO), PepsiCo, Northfield, Illinois-based Kraft and Kellogg Co. of
Battle Creek, Michigan, declined to grant interviews with their
scientists. No one disputes that obesity is a fast growing global
problem. In the U.S., a third of adults and 17 percent of teens and
children are obese, and those numbers are increasing. Across the
globe, from Latin America, to Europe to Pacific Island nations,
obesity rates are also climbing.

28. 16
Cost to Society
The cost to society is enormous. A 2009 study of 900,000 people,
published in The Lancet, found that moderate obesity reduces life
expectancy by two to four years, while severe obesity shortens life
expectancy by as much as 10 years. Obesity has been shown to
boost the risk of heart disease, diabetes, some cancers,
osteoarthritis, sleep apnea and stroke, according to the Centers for
Disease Control and Prevention. The costs of treating illness
associated with obesity were estimated at $147 billion in 2008,
according to a 2009 study in HealthAffairs.
Sugars and fats, of course, have always been present in the human
diet and our bodies are programmed to crave them. What has
changed is modern processing that creates food with concentrated
levels of sugars, unhealthy fats and refined flour, without
redeeming levels of fiber or nutrients, obesity experts said.
Consumption of large quantities of those processed foods may be
changing the way the brain is wired.
A Lot Like Addiction
Those changes look a lot like addiction to some experts. Addiction
“is a loaded term, but there are aspects of the modern diet that
can elicit behavior that resembles addiction,” said David Ludwig,a

29. 17
Harvard researcher and Director of the New Balance Foundation
Obesity Prevention Center at Children’s Hospital Boston. Highly
processed foods may cause rapid spikes and declines in blood
sugar and increased cravings, his research has found.
Education, diets and drugs to treat obesity have proven largely
ineffective and the new science of obesity may explain why,
proponents say. Constant stimulation with tasty, calorie-laden
foods may desensitize the brain’s circuitry, leading people to
consume greater quantities of junk food to maintain a constant
state of pleasure. In one 2010 study, scientists at ScrippsResearch
Institute in Jupiter, Florida, fed rats an array of fatty and sugary
products including Hormel Foods Corp. (HRL) bacon, Sara Lee Corp.
(SLE) pound cake, The Cheesecake Factory Inc. (CAKE) cheesecake
and Pillsbury Co. Creamy Supreme cake frosting. The study
measured activity in regions of the brain involved in registering
reward and pleasure through electrodes implanted in the rats.
Binge-Eating Rats
The rats that had access to these foods for one hour a day started
binge eating, even when more nutritious food was available all day
long. Other groups of rats that had access to the sweets and fatty
foods for 18 to 23 hours per day became obese, Paul Kenny, the
Scripps scientist heading the study wrote in the journal Nature

30. 18
Neuroscience. The results produced the same brain pattern that
occurs with an escalating intake of cocaine, he wrote. “To see food
do the same thing was mind-boggling,” Kenny later said in an
interview.Researchers are finding that damage to the brain’s
reward centers may occur when people eat excessive quantities of
food.
Sweet Rewards
In one 2010 study conducted by researchers at the University of
Texas in Austin and the Oregon Research Institute, a nonprofit
group that studies human behavior, 26 overweight young women
were given magnetic resonance imaging scans as they got sips of a
milkshake made with Haagen-Dazs ice cream and Hershey Co.
(HSY)’s chocolate syrup.
The same women got repeat MRI scans six months later. Those
who had gained weight showed reduced activity in the striatum, a
region of the brain that registers reward, when they sipped
milkshakes the second time, according to the study results,
published in the Journal of Neuroscience.
“A career of overeating causes blunted reward receipt, and this is
exactly what you see with chronic drug abuse,” said Eric Stice, a
researcher at the Oregon Research Institute. Scientists studying

31. 19
food addiction have had to overcome skepticism, even from their
peers. In the late 1990s, NIDA’s Volkow, then a drug addiction
researcher at Brookhaven National Laboratory on Long Island,
applied for a National Institutes of Health grant to scan obese
people to see whether their brain reward centers were affected.
Her grant proposal was turned down.
Finding Evidence
“I couldn’t get it funded,” she said in an interview. “The response
was there is no evidence that food produces addictive-like
behaviors in the brain.” Volkow, working with Brookhaven
researcher Gene-Jack Wang, cobbled together funding from
another government agency to conduct a study using a brain-
scanning device capable of measuring chemical activity inside the
body using radioactive tracers. Researchers were able to map
dopamine receptor levels in the brains of 10 obese volunteers.
Dopamine is a chemical produced in the brain that signals reward.
Natural boosters of dopamine include exercise and sexualactivity,
but drugs such as cocaine and heroin also stimulate the chemical
in large quantities. In drug abusers, brain receptors that receive the
dopamine signal may become unresponsive with increased drug
usage, causing drug abusers to steadily increase their dosage in
search of the same high. The Brookhaven study found that obese

32. 21
people also had lowered levels of dopamine receptors compared
with a lean control group.
Addicted to Sugar
The same year, psychologists at Princeton University began
studying whether lab rats could become addicted to a 10 percent
solution of sugar water, about the same percentage of sugar
contained in most soft drinks.
An occasional drink caused no problems for the lab animals. Yet
the researchers found dramatic effects when the rats were
allowed to drink sugar-water every day. Over time they drank
“more and more and more” while eating less of their usual diet,
said Nicole Avena, who began the work as a graduate student at
Princeton and is now a neuroscientist at the University ofFlorida.
The animals also showed withdrawal symptoms, including anxiety,
shakes and tremors, when the effect of the sugar was blocked with
a drug. The scientists, moreover, were able to determine changes
in the levels of dopamine in the brain, similar to those seen in
animals on addictive drugs. “We consistently found that the
changes we were observing in the rats binging on sugar were like
what we would see if the animals were addicted to drugs,” said
Avena, who for years worked closely with the late Princeton

33. 20
psychologist, Bartley Hoebel, who died this year. While the animals
didn’t become obese on sugar water alone, they became
overweight when Avena and her colleagues offered them water
sweetened with high-fructose corn syrup. A 2007 French
experiment stunned researchers when it showed that rats prefer
water sweetened with saccharine or sugar to hits of cocaine --
exactly the opposite of what existing dogma would have
suggested.
“It was a big surprise,” said Serge Ahmed, a neuroscientist who led
the research for the French National Research Council at the
University of Bordeaux. Yale’s Brownell helped organize one of the
first conferences on food addiction in 2007. Since then, a protégé,
Ashley Gearhardt, devised a 25-question survey to help
researchers spot people with eating habits that resemble addictive
behavior.
Pictures of Milkshakes
She and her colleagues used magnetic resonance imaging to
examine the brain activity of women scoring high on the survey.
Pictures of milkshakes lit up the same brain regions that become
hyperactive in alcoholics anticipating a drink, according to results
published in the Archives of General Psychiatry in April. Food
addiction research may reinvigorate the search for effective

34. 22
obesity drugs, said Mark Gold, who chairs the Psychiatry
Department at the University of Florida in Gainesville. Gold said
the treatments he is working on seek to alter food preferences
without suppressing overall appetite.
Developing Treatments
“We are trying to develop treatments that interfere with
pathological food preferences,” he said. “Let’s say you are addicted
to ice cream, you might come up with a treatment that blocked
your interest in ice cream, but doesn’t affect your interest in
meat.”
In related work, Shire plc (SHP), a Dublin-based drug maker, is
testing its Vyvanse hyperactivity drug in patients with binge-eating
problems. Not everyone is convinced. Swansea University
psychologist David Benton recently published a 16-page rebuttal
to sugar addiction studies. The paper, partly funded by the World
Sugar Research Organization, which includes Atlanta-based Coca-
Cola, the world’s largest soft-drink maker, argues that food doesn’t
produce the same kind of intense dopamine release seen with
drugs and that blocking certain brain receptors doesn’t produce
withdrawal symptoms in binge-eaters, as it does in drugabusers.
*Vyvance has since been approved for distribution by the FDA

35. 23
for the treatment of Binge Eating Disorder as of 2015.
Industry Response
What’s still unknown is whether the science of food addiction has
begun to change the thinking among food and beverage
companies, which are, after all, primarily in the business of selling
the Doritos, Twinkies and other fare people crave. About 80
percent of purchase, New York-based PepsiCo’s marketing budget,
for instance, is directed toward pushing salty snacks and sodas.
Although companies are quick to point to their healthier offerings,
their top executives are constantly called upon to reassure
investors those sales of snack foods and sodas are showingsteady
growth. “We want to see profit growth and revenue growth,” said
Tim Hoyle, director of research at Haverford Trust Co. in Radnor,
Pennsylvania, an investor in PepsiCo, the world’s largest snack-
food maker. “The health foods are good for headlines, but whenit
gets down to it, the growth drivers are the comfort foods, the
Tostitos and the Pepsi-Cola.”
Little wonder the food industry is pushing hard on the idea that the
best way to get a handle on obesity is through voluntary measures
and by offering healthier choices. The same tactic worked for a
while, decades ago, for the tobacco industry, which deflected

36. 24
attention from the health risks and addictive nature of cigarettes
with “low tar and nicotine” marketing.
Food industry lobbyists don’t buy that argument -- or even the idea
that food addiction may exist. Said Richard Adamson, a
pharmacologist and consultant for the American Beverage
Association: “I have never heard of anyone robbing a bank to get
money to buy a candy bar, ice cream or pop.”
To contact the reporters on this story: Robert Langreth in New York
at rlangreth@bloomberg.net; Duane D. Stanford in Atlanta at
dstanford2@bloomberg.net
Closing Thoughts –The Nature of the “Beast”
I’ve chosen a few articles to articulate the physical addiction thesis
representing a sample of what is now appearing in the scientific
literature. One might then assume it reasonable to give
consideration not just to the amount of food prescribed, but its
possible effects on the body. As mentioned, addiction is a complex
interaction between substances and individuals. There is both a
potential for physical dependency, as well as, a psychological one.
Despite the fact people with an eating disorders may vary as to
which of these plays the greater role, suffice it to say both must be
addressed.

37. 25
Likewise, we need to acknowledge the addictive nature of
restricting and the compulsive pursuit of weight loss and resulting
fears surrounding weight gain seen with anorexia. Here the nature
of the substance, food in this case, may be less a factor than the
psychological and physical effects of restricting and resultant
weight loss. However, I would suggest consideration of both the
quantity, as well as, types of food prescribed are equally
important. Given the risk of replacing one form of an eating
disorder for another, a recovery program giving credence to the
characteristics of foods tends to minimize some of this risk. Yes,
quantity is important, but so is the integrity of the food. Programs
encouraging participants to consume “high calorie” foods to insure
rapid weight gain may be setting someone up for developing yet
another form of their disorder. Furthermore, there are other
physical consequences of rapid weight gain and an ill-advised re-
feeding protocol – some of which can be lifethreatening.
For the compulsive overeater and the like, including controlled
portions of junk foods into the food plan carries the risk of giving
short-term success followed by a full blown relapse back into the
eating disorder. Some might argue this point, but I would suggest
it's similar to teaching an alcoholic controlled drinking. He or she
might be successful in a structured setting for a period of time, but
in all likelihood, experience an even worse problem than they had
before beginning treatment.

38. 26
Like many addictive diseases, someone with an eating disorder is
prone to “negotiate” with their disease and, in effect, only change
its' form. Examples of this phenomenon abound in the addiction
world. An alcoholic gives up drinking by replacing alcohol with
tranquilizers. Giving up cocaine, someone resorts to “only smoking
pot.” The compulsive gambler pledges to only “invest” in the stock
market or to only buy a lottery ticket. No longer restricting, the
anorexic begins compulsively exercising to “make up for” the
increased calories consumed while rationalizing they are no longer
starving themselves. Further, the bulimic sufferer can be deluded
into thinking they have found the solution to binging and purging
by restricting. Of course this tends to lead to an even worse relapse
sooner or later.
In my experience, most people with an eating disorder will
eventually experience different forms of the illness throughout the
life cycle of their illness, until they find their footing in recovery.
Regardless of their body weight or appearance, most go througha
bulimic phase, a restricting one, and a compulsive overeating stage
over the course of their disease. For example, someone suffering
with bulimia believes by restricting and not “needing” to purge,
they’ve solved their bulimia problem. Trading in bulimia to become
anorexic is not recovery and vice versa. The denial factor usually is
analogous to trading deck chairs on the Titanic in an effort to avoid
drowning.

39. 27
The bottom line here gets down to recognizing the addictive
nature of an eating disorder and at the same time, accepting the
need for more than a one-sided approach to treatment. To be
clear, the need to respect the addictive nature of certain foods, as
well as, the relentless focus on body weight or body image is a
necessary beginning. However, a program of recovery that limits
itself to only the food and weight piece of the puzzle will likely land
short of the mark. To paraphrase our beloved friend Albert
Einstein, “the same mindset that created the problem cannot be
the same one that formulates the solution.”
Additional References and Suggested Reading:
• Brain Chemistry, Robert Lefever, M.D. and Marie Shafe,
Ed.D.Reprint available upon request via
mlerner@MilestonesProgram.Org
• Opiate-like effects of sugar on gene expression in reward
areas of the rat brain, Spangler, R., Wittkowski, K.M.,
Hoebel, - Laboratory Of Behavioral Neuroscience, The
Rockefeller University, N.Y., N.Y. 2004
Reprint available upon request via
mlerner@MilestonesProgram.Org
• Anatomy of a Food Addiction, Anne Katherine
Text available for Purchase via Amazon.com
or Milestones Bookstore
• Food and Addiction, A Comprehensive Handbook, Edited
by Kelly Brownell and Mark Gold, Oxford Press, 2012
Text available via Oxford Press orAmazon.com

40. 28
Chapter Two
Common Denominators for Eating Disorders
"Everyone is kneaded out of the same dough,
but not baked in the same oven."
Yiddish Proverb

41. 29
Defining the Problem…
Ok, let’s take a moment and “think outside the box” and ask what
all these different “flavors” of disordered eating have in common
rather than what separates them? Is it not true most people,even
medical and mental health professionals, tend to identify and
define an eating disorder in terms of how someone looks or how
overweight or underweight they appear? After all, how can one
suffer with an eating disorder if they don’t appear eating
disordered? And, how is it possible someone can admit to having
an issue with abusing food, excessive dieting, or compulsive
exercising, and not show outward signs?
Even more striking is this perception is too often supported by
many of the treatment programs and self-help groups intendedto
help people find their way into recovery. In effect, this seems to
overshadow the fact that, recovery is about more than just
changing someone’s weight or eating behavior. For most people
with a bona fide eating disorder, body weight and body image
perception are a set of symptoms and [excuse the pun] not the
whole enchilada. Fact is, not all underweight people suffer with
anorexia and not all overweight people suffer with a binge eating
disorder. Suffice it to say there may be a difference between a
weight disorder and an eating disorder. Again, I refer the reader to

42. 31
the APA guidelines [criteria] for dependency to delineatebetween
a weight problem and an eating disorder. (See ChapterOne)
It would seem many people who do not have first-hand experience
of an eating disorder “miss the boat” in this respect. Truth be told,
this is similar to what most people once believed about alcoholism
and drug addiction: alcoholics all wear sneakers, trench coats,and
live under bridges, while all drug addicts live on the streets and
steal money for drugs, and so on. We know differently today. The
overwhelming majority of chemically dependent people cannot be
“picked out of a crowd.” That said, I’d suggest we revisit the
stereotypes many of us have with respect to eating disorders.
This leads us to a retooling of the defining characteristics of all
eating disorders and an assumption I would present to the reader
for consideration.
Eating Disorders are best defined by the degree the relationship
with food and/or body image diminishes the quality of
someone’s life.
A helpful suggestion for newer members of 12-Step programs is to
“identify and not compare.” The reasoning behind this suggestion
is to not provoke the newcomer into a form of denial by telling
themselves something along the lines of “I’m really not as bad as”

43. 30
or “I don’t do what they do every day.” I suspect we could go on,
but you get the idea. The “identifying” piece is about relating to
the experiences and feelings of the other members. To be clear,
anyone suffering with an eating disorder can relate to the feelings
of despair after repeated attempts to “control” their addiction.
Both the anorexic and the compulsive overeater can relate to the
feelings of shame and fear, as it relates to their discomfort with
their body and relationship with food.
What binds people together is more relevant to recovery than
finding what’s unique or different about them. This places
everyone on equal footing regardless of age, gender, socialstatus,
race, religious background, etc. In the end, the common thread
that runs through the community at Milestones has to do with
seeing similarities, not differences and an honest desire to find the
way to recovery. Understanding that as a group, they are able to
do for the individual what they were not able to do alone, is one of
the most important concepts within a therapeutic community.
There is a collective energy, or if you will, a power greater than the
individual at work here.
“If it walks like a duck….”
Just about anyone who has attended a support group such asOA*
or ABA* for a few weeks will likely hear “their story” told by

44. 32
another member. The effect of one person’s experiences shared
with a fellow having the same experiences is, to quote a related
program, “unparalleled.” Once the initial layer of the onion is
peeled, namely the “what makes me different than these people,”
the stage is set for identification rather than comparison. The
question then becomes, “so what do I have in common with
everyone here?” From that point forward, the focus begins to
center more on the solution – “what do I need to do to recover?”
Doing otherwise leaves someone with over analyzing the problem
and little energy left to begin work on the solution.
*OvereatersAnonymous[http://www.oa.org]
*AnorexicsandBulimicsAnonymous[http://aba12steps.org/]
Aside from meeting at least three of the criteria for dependency
we read about in the previous section, eating disorders tend to
have in common the relentless attempt to control how we feel.
Although we’ll look at this more in depth in the next section, I
would suggest that all eating disorders are motivated by an intense
desire to fix or avoid an unpleasant feeling. Although the feeling
may vary within and among persons, the end game remains the
same – control, fix, and change the feeling / discomfort du jour.
One variant on this theme comes from a summary statement made
by a very famous psychoanalyst, Carl Jung. Although I may be

45. 33
accused of butchering his quote for the purpose of making a point,
let’s look at what Carl said:
“All neurotic behavior is an attempt to avoid legitimate
suffering.” – Carl Jung
Restating his rather astute observation, I would suggest…
“Addictions are an attempt to avoid legitimate suffering and, by
this line of reasoning, eating disorders become another way to
avoid legitimate suffering” –
Jung was referring to the symptoms of “his neurotic patients". Let’s
take the compulsive hand washer and his constant fear of germs.
For Carl Jung, this often represents a person’s attempt to control
germs because he is unable or unwilling to admit feeling out of
control in other areas of his life. Perhaps a stretch for some of you,
but consider how often a ”habit” like smoking, biting your nails,
compulsively shopping, or overworking is really a means of
avoiding or distracting us from something uncomfortable and
beyond our control. Again, the point is we often engage in
potentially compulsive or addictive behaviors in a misguided
attempt to “manage” unpleasant feelings. The notion ofaccepting
rather than immediately “fixing” our discomfort is foreign to many
of us.

46. 34
Over time, too much avoidance and distraction have the potential
of becoming addictive, as our tolerance for discomfort becomes
less and less and our need to find relief grows stronger. Unless we
find a more appropriate and less destructive means of reacting to
“legitimate suffering” we are prone to creating a number of
compulsive and addictive behaviors.
Although I would hardly count myself in the same category as Carl
Jung, I do believe he was on to something back in his day. After all,
people do not starve themselves, make themselves sick, take
handfuls of laxatives, binge eat until they’re in pain, exercise to the
point of exhaustion, or engage in any number of painful actions
unless they are attempting to avoid or change their emotional
state. As mentioned, what we see with eating disorders is a
progression of first attempting to feel better followed by an
attempt to delay or avoid feeling bad [withdrawal] in the later
stages. I’ve seen this to be as true for someone in the midst of
anorexia as someone struggling with a binge eating disorder. The
same can be said for almost alladdictions.
Another similarity within the ED population has to do with the
incidence of coexisting mood disorders. More often than not
recurring depression, anxiety, and marked mood swings come with
the territory. In addition, more than half the people seeking
treatment have histories of abusing alcohol, drugs, and/or other

47. 35
forms of self-abusive behaviors like cutting. Regardless of the
particular eating disorder, it’s rare to see someone with an ED
without an accompanying mood disorder, chemical dependency,
or self-abuse issue.
Table 2.1
Similarities among the EatingDisorders
- The majority of people with an ED meet the established
criteria for [addiction] dependency per the same criteria
typically reserved for substance dependencies*.
- ED behaviors are initiated in an attempt to avoid or change
uncomfortable feelings - usually negative feelings and
emotional states.
- Most eating disorders typically are associated with a mood
disorder that often pre-dates the beginning of the eating
disorder.
- Regardless of ED type, at least half the people coming to
treatment for an ED also have abused alcohol, drugs, or
relied on additional forms of self-medication.

48. 36
- Having an ED makes someone vulnerable to “switching
addictions” throughout the life cycle of their ED.
- Independent of the form of ED, control issues are a central
theme needing to be addressed – first with food and
weight, and later with other areas of daily living such as
relationships.
- With the exception of some subtypes of anorexia, most
people suffering with an eating disorder react to certain
foods [e.g. sugar derivatives, refined flours, highly
processed junk foods, etc.] differently than their non-
eating disordered peers. *see D2 receptors and eating
disorders
- Both psychological and physiological factors are inherent
among all forms of eating disorders. Physical dependency
and psychological dependency interact to create an
addictive relationship with food, body weight, and/or
dieting.
- Long-term recovery from an eating disorder requires
significantly more than a temporary change in someone’s
body mass index [BMI / weight / appearance] and eating
pattern.

49. 37
- Recovery often requires the ongoing participation in a
support group or a continuing care plan after formal
treatment ends.
- Appropriate [non-habit forming] medication[s] usually are
needed to treat co-occurring depression or a similar issue
accompanying an eating disorder. In many instances, the
mood disorder is a “stand alone” diagnosis that exists with
or without the ED.
- Most people with an eating disorder have some level of
impairment with an ability to differentiate between
hunger [physical needs] and appetite [psychologically
driven]. – internal versus external cues of hunger
- As with other addictions, remission is a more realistic
expectation with treatment outcome rather than a “cure.”
In effect, addiction is a life-long disease that can be
arrested by remaining engaged in consistent recovery
related activities. Remission can be life-long or short-term.
Co-Existing Addictions and RelatedProblems
Those of us who have been in and around the recovering
community are quite aware of the prevalence of eating disorders
within the fellowships of Alcoholics Anonymous, Narcotics

50. 38
Anonymous, and related 12-Step groups. This recognition of the
correlation between eating disorders and addictions - chemical
dependencies and process addictions* alike, is gaining increasing
attention in the popular press and research literature.
Although there are no exact figures, a conservative estimate of the
percentage of chemically dependent women who would“qualify,”
as eating disordered likely is in the neighborhood of twenty to forty
percent. There are no gender-specific studies regarding “cross-
addiction.” However, there is evidence to suggest that, of all the
cases diagnosed in the general population, at least ten percent are
male. Certainly, when we speak of “disordered eating,” we are
including all those suffering from the most widely recognized
eating disorders including anorexia, bulimia and binge eating
disorders. Although many individuals suffering with an eating
disorder may appear significantly overweight or underweight, like
most alcoholics and drug addicts, one cannot identify someone
with an eating disorder simply by appearance. *Processaddictions
include compulsive gambling, shopping, sex, and those thought to
involve habitual patterns of behavior and not attributable to a
drug, chemical, or other substance.
When we look at an addiction, and in this case we’re looking at
eating disorders, we’re really apt to discover the existence or
predisposition toward another dependency – if not several. One
way to conceptualize this cross addiction phenomenon is depicted

51. 39
in Table 4.1. The table represents a hypothetical list of other
addictions that may or may not be secondary to the eating
disorder. These may be co-existing at the time of treatment or
represent prior forms of self-medication or addiction. This
particular pyramid is fairly representative of the collective issues
often seen in the treatment setting, coinciding with an eating
disorder. Naturally, there are individuals that do not fit this model
and come to treatment with no history of co-existing addictions.
However, such folks would be well advised to be on the lookout for
the potential to exchange the form of their eating disorder or
develop a new dependency in the course of their ongoing recovery.
TABLE 4.1 – Sample – The AddictionPyramid
EATING DISORDER
CHEMICAL DEPENDENCY
C O - D E P E N D E N C Y
N I C O T I N E / C A F F E I N E
G A M B L I N G / C U T T I N G / S P E N D I N G
Interspersed with co-existing addictions and related forms of self-
medication are mood disorders. The most frequent of these
include recurrent depression, anxiety disorders such as panic
disorders, phobias, generalized anxiety, and bi-polar disorder. The
prevalence of mood disorders associated with an eating disorder
is estimated to be in the range of 80% or more. This is greater than

52. 41
any other addiction including drugs, alcohol, or any of the process
addictions. Very often a combination of the appropriate therapies
is necessary to treat these issues at the same time as addressing
the eating disorder. Regardless of whether a mood disorder pre-
dates the beginning of an eating disorder or came about as a result
of one, it’s imperative to diagnose and treat it.
As a point of information, the majority of patients presentingwith
a depressive disorder usually identify their depressive symptoms
as predating the onset of the eating disorder. In such instances the
depression may be considered an independent illness and, if left
untreated, will likely persist beyond the treatment of the eating
disorder. The implications are two fold – first, the medication piece
may need to be life-long as the diagnosis is one of recurrent
depression and not a single episode and, second, thecontinuation
of the medication is one of minimizing the risk of recurrence of
another depressive episode and relapse back to the eating
disorder. Still another group of eating disorder patients present
with depressive symptoms directly related to the eating disorder
and, as such, represent a single episode of depression or
depression secondary to their eating disorder. For this group,
medication can be recommended for periods up to a year or so
with the depressive symptoms improving significantly with the
remission of the eating disorder. However, unlike recurrent
depression, antidepressant medications are not necessary for
long-term maintenance of recovery with this group. A

53. 40
conversation with the prescribing physician regarding yourhistory
and diagnosis, apart from the eating disorder, will help you
understand what needs doing on the medication front.
Defining - Medication or Drugs?
It may be helpful to delineate between using medication and using
a drug. Medication is intended to put people on a par with reality
and capable of benefiting from other forms of therapy. Drugs tend
to dull a sense of reality and usually are taken to deaden or alter
feelings. Some prescription medicines can be abused as drugs,
such as stimulants intended for attention deficit disorders, but are
used instead to get high, while others are of great benefit when
taken as directed. * Medications, then, can be a tool in recovery or
misused as a means of furthering ones’ disease. In fact, the same
prescription drug can be used as a medication for one person and
as a recreational drug or “diet pill” for another.
The more frequent diagnoses and issues accompanying an eating
disorder are shown in Table 4.2. These represent a sample of
issues we frequently see at our facility, as well as, what other
programs need to consider with ED treatment.

54. 42
TABLE 4.2 – Dual Diagnoses + ED
- Alcohol Abuse and Dependency
- Major Depression - recurrent and single episode
- Bi-Polar Disorder
- Anxiety Disorders – phobia and generalized
Anxiety
- Drug Dependency - Prescription Meds, Street
Drugs, etc.
- Alternating Eating Disorders – Binge Eating >
Bulimia
- Nicotine Dependency
- Borderline Personality Disorder
- Obsessive Compulsive Disorder
- Process Addictions – Compulsive Gambling,
Shopping, Sex
- Impulsive Control Disorders - Shoplifting
- ADD – with or without hyperactivity

55. 43
Cross Addiction and Co-Existing Issues
The take away from this topic is simply to recognize addictions and
compulsions are often misguided attempts to manage or control
our feelings. That being the case, it would seem likely when we
stop using one means of doing this we’re prone to “go back to the
well” and rely on another. The important thing here is to accept
the need to work on the problem [nature of the person] and not
just the symptom [the addiction]. Be patient, be cautious, and be
honest with yourself. Some of these issues can be tackled along
with your eating disorder treatment and some will be taken on
later in the course of your recovery. Which one and when will
depend on how they threaten your eating disorder recovery and
whether you can “buy time” to work on them at a later date.
Body Image and Body Dysmorphic Disorder
I’ve always been fascinated by the “disconnect” between how we
experience our speaking voice and how it sounds when we listen
to it from a recorded device. Likewise, there’s the tendency to view
different photographs of ourselves and wonder how we could look
so different in each one, yet almost everyone else hardly notices
any change. How can we see the same picture so differently from
others? Is it possible our perception is influenced by factors we’re
not totally aware of? To be clear, this phenomenon of perceiving
and experiencing ourselves differently from the “outside world” is

56. 44
common to all human beings. The issue, however, rests with the
tendency among many people exaggerating this “discrepancy” in
the service of self-criticism and a distorted sense of self. Few
populations exemplify this distortion of reality as those suffering
with an eating disorder.
Body image distortion, as it relates to eating disorders, and its
“cousin”, body dysmorphic disorder, is perhaps the most
pronounced example of how these “disconnects of perception””
dominate the thoughts and feelings of ones’ daily life. Toillustrate
this “in the eyes of the beholder” phenomenon, many of you may
be familiar with the “old or young woman” optical illusion (see next
page).
Although there may be an infinite number of “theories” as to how
the brain processes the physical world vis-à-vis our senses, the fact
remains there is no clear cut understanding to account for the
relentless perception of either an undernourished or healthybody
being overweight, or a pop star enlisting an army of surgeons to
alter his nose repeatedly until he must wear a mask in public. At
the very least, it would be reasonable to say many of those
suffering with anorexia, bulimia, and in many cases binge eating
disorder, have in common some degree of “confusion” as to how
they really appear.

57. 45
What do you see? Is it a profile of a young
and beautiful lady, or do you see an old
woman with a huge and ugly nose?
Body Image and Body Dysmorphic Disorders
are typically not about vanity per se. Fact is, body image issues can
be found in all subtypes of eating disorders, although most
commonly associated with anorexia. As we’ve seen, eating
disorders are often associated with people with exaggerated needs
for control, perfectionism, and insecurities that appear to focus on
appearances. To be sure, there is a difference between someone
with a “weight problem” and one with a bona fide eating disorder.
The latter usually having to deal with the confusion over perceived
body image and a pathological relationship with food and weight.
Most of the “dieting off and on” folks do so without a serious
disruption to their lives. They are what some refer to as the
“worried well.” Such is not the case with an eating disorder. That
being the case, let’s look at one hypothesis.
Through the years, I’ve come to experience mood disorders, in
particular forms of depression, as the “chicken before the egg”
regarding body image and body dysmorphic disorders. In reality, it
is more the rule than the exception that a mood disorder
accompanies, if not “pre-dates” the onset of an eating disorder. To
be clear, our mood will more often than not color our perception.
In other words, the more depressed, the more negative our view

58. 46
of ourselves. The “smoke and mirrors” effect of an eatingdisorder
then goes something like this: “I look in the mirror and I see myself
as and that’s what really makes me feel depressed. If I were
able to change the way I look then I wouldn’t be so depressed.”
Hence the anti-depression fix becomes changing the body or
numbing the pain with further restricting or binge eating, etc. The
angst of how we experience our body is believed to be the problem
and the solution becomes changing the body at any cost – evento
the point of engaging in life threatening behaviors.
I’m not proposing the solution to a body image issue is simply
“buying into” this theory or finding the right “medication.” What I
would suggest is at a minimum conceding your “perception” is a
confused one and giving consideration to putting your energyinto
a recovery process. That process would give equal time to
following a treatment plan that includes a healthy food plan,
abstaining from your eating disorder behavior[s], with professional
help if necessary, and also finding a way to appropriately manage
your depression. Last, but not least, I would be remiss not to
mention that more than half of the people we see at Milestones
also have relied upon alcohol, drugs, or other compulsions in
addition to their ED in a misguided attempt to “control” their
depression and perceptions.
In sum, body image disturbances are a prominent feature of most
eating disorders. Whether they are a symptom of an underlying

59. 47
issue with a mood disorder such as depression or generalized
anxiety disorders, a manifestation of past trauma, or any number
of factors often associated with eating disorders may not be
important. What matters is the need to acknowledge body image
disturbance as a symptom of the disease – more so for some, and
less so for others. Another point to consider is resolving the
depression or underlying mood disorder does not guarantee the
resolution of a distorted or negative body image. That said feelings,
thoughts, and perceptions about our body become less
troublesome over time if following a recovery program. By
incorporating the principles of a 12-Step program and some ofthe
principles discussed, we can learn to live with our imperfections.
The frequency and intensity of negative experiences with our body
will diminish. Self-focus and a renewed interest in other people
and things beside ourselves will usually follow.
Internal and External Cues: What also makes usdifferent?
My experience has been eating disorders almost uniformly involve
a broken thermostat-like mechanism that governs internal cues
[symptoms] of hunger and fullness. In other words, unlike our
“normal eating” contemporaries, we are often confused when to
eat, what to eat, how much to eat, and/ or when to stop eating.
Whether suffering with anorexia, bulimia, or compulsive
overeating, there is a tendency to be more governed by external
stimuli - such as the sight of food, smells, time of day, stressful

60. 48
events, body image, etc. These influence our behavior around food
more than the internal cues such as blood sugar levels, stomach
contractions, an empty stomach, and so on. Just how much do
these factors mediate our eating behaviors?
We seem more susceptible to being conditioned to associate
certain emotions or external events with turning on or off our
appetite. Again, another way to look at this may be that our
circumstances and psyche tend to “trump” our physical needs or
internal signals when it comes to our eating. To date, science has
yet to figure out whether this is a learned behavior or one some of
us prone to eating disorders are born with.
Given both the effect certain foods exert on our brain chemistry
and this external orientation regulating our appetite, we need to
have a plan to take both factors into consideration. Again, there is
the nature of the person and the nature of the substance
interacting here.
The “plan” needed begins with some structure and realistic
boundaries around our eating. In my humble opinion, it is why an
“intuitive eating” approach is not the best route to take with food
planning and eating in general. There is a need for limits around
the types of foods we eat, a reasonably consistent schedule of
when we eat, and an acceptance of some of the physical and

61. 49
psychological differences that separate us from our “normal
eating” peers. The same can be said for people suffering with a
variety of other substance and process addictions. Although the
differences may be unique to their particular problem, they too
differ from their non-dependent peers. By way of example, allow
me to tell you a little bit about my friend Harry.
My Friend Harry….
Everyone with an eating disorder has known a Harry or Harriet, if
you prefer. You know the type. Harry never worries about weight
or what he eats. Perhaps you sit at the local diner staring at the
“low calorie plate” in front of you - typically an all-beef patty
without the bun, a wilted piece of lettuce with a scoop of large curd
cottage cheese atop a pear half with a Diet Coke - and glance across
the table at your friend Harry. There’s Harry with his cheeseburger,
fries, and a cherry coke. As an evil fantasy crosses your mind of a
sudden and painful demise for Harry, you quietly slide the
remainder of his meal over to your side of the table, while
paramedics work to restore his pulse. As you finish the last fry and
take the final bite of his burger, you gently place the bill in his
lifeless hand and tell the server “he’s got the check.” Suddenly
you’re startled from your daydream when the waiter returns and
asks,“anyone want dessert?” Harry replies, “How’s the
cheesecake today? What a nightmare.

62. 51
Ever notice your “Harry or Harriet” taking a “taste” of the cake and
leaving it at that, or perhaps pushing away their half-finished plate
because “they’re full”? Chances are Harry relies more on his
internal guidance system than being led around by all theexternal
stuff. With eating disorders this guidance system is pretty much
broken. It's not so much that Harry has a “better metabolism” than
you. Fact is our friend’s behavior around food is not hijacked by all
the external and emotional stuff the way we are.
Growing up, I remember when my mother would become nervous
or agitated over something she would tell us “I’m so upset I can’t
even think about food.” Sounds like she’s a Harry or Harriet type.
Although that may be the case for some people, lots of us might
have the opposite reaction, soothing ourselves with “comfort
foods.” Still others would find it not only difficult to eat when
upset, but also find the act of eating by itself unsettling. We’re
looking at emotional eating or restricting as a reaction to events
and stimuli outside ourselves, hence, external cues and
perceptions trumping our biological cues.
A Quick Footnote about Harry….
By the way, Harry also habitually left over half a Martini and
seemed to be able to “take or leave” most things that people
usually consume. In fact, Harry never seemed to become too

63. 50
dependent on anything or anyone. Imagine that! Oh well - maybe
in the next life.
The Restricting Side of the EDCoin
Then again, you may be at the other end of the eating disorder
spectrum. With more of an anorexic pattern, there is either a
denial or misinterpretation of our physical needs or, more
typically, a phobia of what will happen to us if we “give in” to our
hunger and feed ourselves. The “phobic” response to eating and
the never ending pursuit of being “thin enough” seems to come
with the territory. Fact is, there is a general mistrust of what the
body is telling us internally and an over reliance on external
perceptions and stimuli that further our “Dis-Ease.” Even when
“listening” to your body, you’re likely to continue to mistrust both
the message and the messenger.
In sum, over feeding and under feeding are simply different sides
of the same coin. Both are perpetuated by a chaotic array of mixed
messages from our internal selves and what we perceive on the
outside. All this makes for a relentless battle between our bodies
and our minds. Not a fun place to be.
One of the positive outcomes of recovery comes when we accept
we are not a Harry or Harriet type. In some circles this is referred

64. 52
to as a cucumber becoming a pickle never to return to being a
cucumber again. Being a pickle, however, does have its
advantages. With acceptance of our reality, the adoption of a
reasonable food plan becomes a preferred place to be ratherthan
a prison sentence. *Clean eating, along with the other components
accompanying a recovery lifestyle become a matter of preference
and not something we do because “we have to.” You’ll find the
same experiences among people enjoying long-term recovery
from alcohol, drugs, and other dependencies - namely their
“recovery” has become a blessing and not a curse. I’d further the
analogy to someone with any chronic disease. If we we’re
discussing diabetes treatment then eating within the bounds of a
healthy whole-food plan, moderate exercise, managing stress, and
developing a personal sense of spirituality would be the exact
prescribed program called for. If you think about it, this formula
would serve anyone with a chronic disease and go a long way to
restoring someone’s health and quality of living.
[*]It’s important to remind the reader our reference to “abstinent
food plans” and “clean eating” are about healthy and adequate
nutrition and not in the service of further restrictingcalories.

65. 53
And the Good News Is…
The good news is long-term recovery from an eating disorder is
entirely possible. The bad news is it requires hard work. Following
the right course of treatment, following an appropriate recovery
program, adherence to a healthy food plan, and addressing the
problems often accompanying an ED, are key to achieving this goal.
Few do it alone. There is a roadmap, a way out of the woods, so to
speak.
I often suggest to people engaged in the treatment process at
Milestones to consider doing as near 100% of what is being
suggested as possible. Those doing their best will likely take with
them enough of what’s needed to stay in recovery. However,
should someone be cutting corners, modifying and devising their
own version of a treatment plan – namely doing only what they
believe applies to them, they usually end up in relapse either
before or shortly after they finish treatment – or they leave with
only a “diet” instead of program for recovery.
That being said, the primary purpose of this text is to set the stage
for recovery. Doing so first necessitates defining the problem.
Hopefully we’ve made a reasonable start in doing just that. Next is
asking yourself if you’ve reached the point of willingness –
specifically to commit your energy and faith into “living in the

66. 54
solution” rather than staying stuck in the problem. Should you be
at that point, the suggestions and information forthcoming will
help you get where you want to go.
**********
Additional References:
Available upon request
mailto:mlerner@Milestonesprogram.Org
What comes first, the Chicken or Egg? – Why, It’s the Egg!
There is a physics experiment that may serve as a metaphor for
recovery. This demonstration is intended to prove it possible to
place our recovery first and still have time to get everything else
done. If I can borrow your imagination for a few minutes you’ll see
what I mean.
First picture a large Tupperware Bowl, with the lid off, filled with
uncooked rice, about a half inch from the top. The rice symbolizes
all the stuff we need to get done on any given day – the laundry,
preparing meals, going to and from work, our jobs, getting our hair
done, feeding our dog, cat, or kids, going to the dentist, taking a
shower, getting the oil changed in the car, and on, and on, and on.
Next, take four hard-boiled eggs. Each egg now represents one of
the four basics of recovery - S.E.R.F. Please make sure the eggs are
hard boiled so they don’t make a mess. Place the eggs on top of
the rice and try and close the lid. It won’t close. So… youeliminate
one of the eggs. Still won’t close. Ok, you take away another one,

67. 55
no cigar. Eventually you might get it to close with one or two eggs
left. Not much recovery left here. Maybe your SERF is reduced
to EF.
And now…. Take an identical size bowl that’s empty and place it
next to the original one. Now take all four [SERF] eggs and place
them in the empty bowl FIRST. Now pour the same rice from the
original bowl over the eggs on the bottom. And, finally, place the
lid on the bowl. Guess what – it fits.
Believe it or not, this is something we actually do as a
demonstration from time to time at Milestones. In reality, we’ll
find ourselves with more than enough time to take care of what
needs doing when we put our recovery first and allow the rest of
our daily stuff to fall into place. Being consistent with the SERF
basics is one of the paradoxes of recovery – namely putting
ourselves first-positions us to better take care of everything else.
As has been mentioned repeatedly throughout this guide Doing is
Believing.

68. 56
Chapter Three
Recovering from an Eating Disorder
"Some of us think holding on makes us strong,
but sometimes it is letting go."
-Herman Hesse

69. 57
The Roadmap
When all else fails, follow the directions” – anonymous
Ok, now we’ve come to the instructions. You know, the written
materials [aka instructions] most people either discard or only
glance at while putting together whatever it is they’re trying to put
together. If you’re like me, you usually end up with a bunch of parts
left over and something that doesn’t quite look like the picture on
the box. This may be a time to do it differently. A word of caution
- it’s not unheard of for people with, shall we say, control issues,
to be slightly defiant and a tad bit stubborn [a little sarcasmhere].
If this doesn’t apply to you then I would suggest you may be inthe
wrong place or, more likely, are having one hellacious issue with
denial. Fact is, most people who suffer with an eating disorder,
have more issues with control and trust [what a surprise] than their
non-addict peers. These two issues are a central theme of what
needs to be addressed in the recovery process. We’ll talk about
control and trust in a few pages.

70. 58
A Word About “Therapy”
“So What, Now What?” - unknown
Least we’d be remiss if we didn’t provoke a little controversy here.
Allow me first to confess to being someone with both professional
and some personal experience with eating disorders and
addiction. This leaves me with a distinct, and perhaps subjective
take on what works and doesn’t work. Likewise, our clinical team
at Milestones has come to appreciate a similar perspective. That is
to say the approach to recovery that works best is one ofteaching
the skills needed to keep it. Doing so does, however, require
putting these skills into practice on a daily basis. The saying that
best describes this philosophy is simply “teaching someone how to
fish is far better than feeding them a fish.” Hence the goal is doing
recovery rather than knowing about it.
What Works and Doesn’t Work?
“Quitting is easy; I’ve done it countless times.” - unknown
Let’s begin with what doesn’t work. Traditional forms of
insight oriented, psychoanalytic, and various other therapies
relying on a revisiting and reframing of the past are among the
least promising approaches. In other words, coming to

71. 59
understand what “caused” your eating disorder and
“connecting the dots” has little effect on a successful outcome,
unless it directs someone to take action in thepresent.
Through the years I’ve come to know a number of people
struggling with anorexia, bulimia, binge eating, and a number
of other related issues. Almost all had some form of traditional
counseling or therapy prior to coming to a residential program
like ours. With few exceptions, they had tons of insight as to
when, where, why, and how their addictive relationship with
eating or dieting began. For some it was related to control
issues, using their need to control food and weight in lieu ofnot
being able to control other parts of their lives. For others it
had to do with a misguided attempt to deal with a traumatic
event such as sexual or physical abuse. The list can sometimes
be endless. Perhaps the question one should ask is “so what, now
what?”
Their accounts suggest self-medicating with food or restricting
after developing a deep sense of distain for their bodies. In the
end, identifying the causes had little to do with overcoming their
ED. In my opinion, by the time someone reaches the point of
wanting to stop an eating disorder it has acquired a life of its own.
The same can be said for all addictions. I know of almost no
exceptions. In fact, intellectual understanding of the problem only

72. 61
adds to the frustration and pain of not being able to stop – even
when you want to. To paraphrase a concept from the text of
Alcoholics Anonymous: “we reach a jumping off point, where we
can no longer live with our addiction or live without it.” Anyone
suffering with an eating disorder has probably experienced this.
Not to be excluded, therapies that focus on “feelings” and
expression of emotions may be helpful to some folks, b u t
appear to have limited value. Not to say they don’t result in
someone feeling better for a period of time, but the
assumption that getting in touch with ones' feelings and
expressing them is the key to resolving an eating disorder is
simply mistaken. Getting in touch with feelings has long been
the Holy Grail among many therapists, counselors, and eating
disorder programs. Feelings have their place in many arenas
such as marital counseling, anger management, anxiety and
mood disorders, etc. However, my experience has been they
have limited value in the recovery world, unless they are in the
service of directing someone to a specific course of action,
which at times can mean simplywaiting and exercising restraint.
Taken together, cognitive behavioral therapies, dynamic or
analytic therapies, behavior modification, rational emotive
therapies, pharmacologic therapies, gestalt therapies,
massage therapies, wilderness therapies, homeopathic

73. 60
therapies, alternative therapies, and so on – all may be
helpful to varying degrees. However, there is one important
caveat, namely none of these alone provides a definitive
“cure” for an eating disorder or any other addiction that I’m
aware of. Not to beat the proverbial dead horse, but
combinations of many of these techniques may have varying
degrees of benefit - so long as there is no expectation that any
one approach alone represents the “silver bullet” eradicating a
severe eating disorder or related addiction.
Therapy or Therapeutic Setting?
Recovery, to be sure, begins with stopping the addictive
behavior. The next challenge is staying stopped. Doing so often
requires the help of something other than simply good
intentions or resolutions. Few can do this alone. In the eating
disorders world many, if not most, need the collective energy
of a group of other people in a similar dilemma – all who want
to recover. Although a 12-Step or other related support group
may provide this in the long run, often it requires treatment
within a structured and supportive setting to get started.
Powerful and effective as they may be, 12-Step, SMART
Recovery, and similar community based groups offer great
long-term support, but are not intended to replace treatment
when it’s needed.

74. 62
A residential or day treatment program can enhance the
chances of getting an initial handle on your eating disorder.
Apart from the benefits of an experienced treatment team, the
appropriate treatment setting is essential for making the
transition from an eating disordered life to a recovery one
possible. The work of creating, facilitating, and managing a
therapeutic community then becomes the primary mission of
any program. Once in place, the work of learning and putting
into practice longer-term recovery skills begins. We often like
to say – “the magic is in the community.” Here’s an excerpt
from the Milestones literature summarizing a mission
statement for our program and facility:
“Milestone's primary purpose is to provide a
comprehensive program to address the
specific needs of individuals suffering with an
eating disorder and the issues often
accompanying them. Providing a safe,
structured, and effective course of treatment,
the facility offers apartment - style residences,
on-site support and a multi - specialty team of
licensed professionals. The program also offers
residential, as well as, day treatment levels of
care. We are a therapeutic community whose
mission is to provide a healthy, safe, and more

75. 63
sustainable lifestyle. Many refer to this as a
recovery lifestyle. The program follows a
"blended" approach to treatment - addressing
both the addictive and emotional aspects of an
eating disorder. Residents attend a fullschedule
of group and individual activities during the day,
as well as, participate in various support groups
during evenings and weekends. Grocery
shopping, meal preparation, and "real world"
experiences are an integral part of the
program.” [*]

76. 64
The Secret to Recovery
Here’s a brief story from a few years ago. Ok, a couple of decades
ago. Anyway, I was a student intern at a fairly renowned
psychiatric hospital and the chief of the psychiatry division, who
appeared to be a rather charismatic and bright fellow, was
taking us on rounds. All of a sudden, out of nowhere, comes
this raging patient who parks his face right in front of the chief’s.
He starts shouting, “how come you won’t tell me the secret?
How come you told John and he’s better now and getting out?
How come you won’t let me know the secret? What’s the
secret to getting better? What’s the secret, tell me.”
Here’s a little background on myself at this point to put this
in perspective. First off, since childhood I always had the
impression I would be “told more about something” or let in
on “the family secret” when I was older. You know the drill.
So, my immediate flashback had to do with the notion that
there was always some secret, some magical answer, drug,
formula, whatever, that would be revealed to me “one day.”
Then, when you become an accountant they bring you into a
room full of accountants and tell you the accountant secret, or
you finish law school and they tell you about the secret
handshake, or you pass your flight test and they tell you the
secret pilot code. Got it? Ok, back to the story.

77. 65
Now the chief of psychiatry, without moving so much as a
muscle or batting an eye asks the patient, “So you want to
know the secret, the secret to mental health, the secret to
getting better?” Meanwhile we interns are soiling our
underwear about now. “Yes”, screams the patient, “tell me, tell
me.” Without hesitation, the chief replies, “ok, you want to
know the truth, the secret?” Again, “yes, tell me, please tell
me the secret.” The chief looks directly in his eyes and says -
“hard work.”
To me this was so profound. Why? Because like most of us who
are predisposed to some form of an addiction or compulsive
behavior somehow believe there is a quick fix, answer,
remedy, solution to what ails us. Maybe we think it will be this
new drug, a new diet, this new relationship, a new therapist, and
on and on we go. It wasn’t until several years later that I came
to realize just how right this teacher was. Fact is he was talking
to all of us. If you really want to now the secret and you’re
ready to learn the truth, then be prepared to do the work.
As the saying goes, “faith moves mountains, but be sure and
bring a shovel.”

78. 66
Living in the Solution: The HardWork
Rather than a specific therapy, there is a philosophy that appears
to hold the key to binding all this treatment and recovery stuff
together. Interestingly enough, an anthropologist named David
Reynolds introduced me to this “philosophy” several years ago. Dr.
Reynolds, who last I heard lives in Hawaii and holds a faculty
position at UCLA’s medical school, wrote a book in 1984 with the
title Constructive Living. The good professor chronicled specific
psychiatric approaches taught in Japan referred to as “Morita
Therapy”. He then took these concepts along with another
approach, “Naikan Therapy,” interpreted and summarized their
essence for his book. Having been exposed to what Reynolds refers
to as Constructive Living and putting some of these principles into
practice; it’s become an integral part of the program philosophy at
Milestones. In fact, I have remained both teacher and student with
respect to most of the concepts suggested by this lifestyle. Over
the years I’ve come to recognize all the parallels between a 12-Step
program and a Constructive Living one. I encourage you to keep
an open mind and give careful consideration to what follows. It is
intended only as a brief and simple description of what this
program entails.
*Morita therapy is credited to Japanese Psychiatrist, Dr. Morita
and is the principle impetus for Constructive Living therapy. Naikan

79. 67
therapies are attributed to another Japanese physician. It centers
on the practice of a specific focus for meditation and reflection. It
is akin to the concepts of “mindfulness” and gratitude – both
corresponding elements in a 12-Step philosophy. A more detailed
explanation of these techniques can be found in the Constructive
Living text referred to earlier.
Principles of ConstructiveLiving
There are a few basic elements that deserve mention before we
proceed with the “laws of human behavior” about to be outlined.
Many of these fly in the face of what most of us mental health
professionals were taught – at least as it applies to psychotherapy.
I want to add a little disclaimer here and propose a couple of ideas
to consider regarding this Constructive Living (CL) approach.
- The CL approach is not psychotherapy
- CL is basically a form of discipline
- Progress is better measured by behaviorsrather
than feelings
- Feelings usually follow behavior

80. 68
At first glance these concepts may seem simple enough. However,
there is more to this stuff than meets the eye. There seems to be
an implied assumption in the world of mental health treatment
that goes something like this: if we can change how someone feels,
or if we can change what thoughts they have, then we can get
someone to change what they’re doing. I suspect most of us hold
onto the belief that goes something like this - if a therapist or
someone I looked to for help could fix how I feel, then maybe I
would be able to _. You fill in the blank. Try this one on for
size: “If or when you can help me feel better about my body I will
buy shorts and exercise.” “When I don’t feel so big I’ll let myself
eat.” "When I’m not so nervous, I’ll speak in front of the class and
be able to do the presentation.” “When I get [aka feel] motivated,
I’ll study.” No doubt we can make an endless list of “when I feel, I
will.” Experience has shown repeatedly when we put a “state of
mind” as a condition for doing something we’re likely to be stuck
in the problem. Conversely, when we develop the discipline of
doing what needs doing despite the feelings or intrusive thoughts
we are moving toward the solution. Let’s take a few minutes and
look at the basic principles of this philosophy and explore it. I’ve
taken the liberty of paraphrasing some of the CL principles David
Reynolds talks about in his text. They are:

81. 69
- Feelings are not directly controllable by self will
- Feelings need to be recognized and accepted “as is”
- Every feeling, no matter how unpleasant, has a
purpose
- Feelings fade over time, unless re-stimulated
- Feelings [and thoughts] can be indirectly
influenced by behavior
- We are responsible for what we do no matterhow
we feel
If you really consider these, they tend to appeal to our common
sense and really don’t require a degree in rocket science. However,
taking a more detailed view and truly contemplating these you’ll
notice a much more profound meaning. What is being proposed
are a set of what could be called, universal truths about the human
mind and how it operates. It suggests trying to control our feelings
by directing energy into simply “willing” ourselves to feel
something is a wasted exercise. Try sitting down in a chair when
you’re feeling sad and “will” yourself to feel happy for any
extended period of time. Try willing yourself to fall in love with
someone you’re not in love with. Likewise, controlling your
thoughts by imposing self-will is quite limited as well. Ever tell

82. 71
yourself not to think about something? I usually end up obsessing
about something the more I try or am told not think about it. The
“magic sauce” in all this is that our thoughts and emotions can be
indirectly influenced by what we do. In other words, what we do
has the greatest [probable] impact on what we think and feel over
time. The cart is placed before the horse when we get it backwards
by insisting we fix our feelings first. Believing our feelings and
thoughts must be changed before we’re able to change our
behavior can be a very costly mistake.
Once again, eating disorders and addictions are about fixing
feelings. Now we can add another idea, this time regarding the
solution – “recovery is about transcending our need to fix how we
feel and doing the next right thing no matter what we’re feeling.”
This challenges the belief that controlling our feelings and thoughts
is the primary goal of psychotherapy. Instead we’re proposing the
reverse - controlling our actions and letting the feelings and
thoughts take care of themselves. “Doing is believing” as I like to
say.
Feelings and thoughts, as we’re reminded, are never constant.
Much like weather patterns, our emotions and thoughts are always
changing. They come and go. In this sense, nothing stays the same.
Trying to exert control over these is like trying to control the
weather – not possible. Behavior, with very few exceptions is

83. 70
within our control. Being consistent with what we do is achievable.
The few exceptions I know of have to do with some physiological
stuff – like holding your breath for five minutes or not shivering in
the cold weather or making yourself fall asleep when you suffer
with insomnia, and so on. It’s a short list.
And for the Perfectionist…
Just a brief note to those who tend to sit on the perfectionist side
of the ED fence – “sometimes the “what needs doing” is about
“what needs to not be done.” Most of us who suffer with some
form of an addiction or compulsive disorder tend to display the
trait of dichotomous thinking and behavior. In other words, we
tend to be all or none types, thinking and doing in terms of feast or
famine and living in a black and white world with little room for
any shade of gray. This being the case, some will need to use more
restraint in their recovery program, being less perfect with certain
elements and being mindful of not “over-doing”. Others may
benefit by being more vigilant or compulsive with recovery
behavior. As it relates to an eating disorder, this balance will work
best combined with a prescribed food and exercise plan, a
balancing of work and play along with our overall recovery
activities. Given these extremes, we see people who either weigh
and measure their food to the nearest atomic particle, the over-
doers, or skip weighing or measuring entirely and “count” only the

84. 72
amount of food they consume when sitting down - as if standing
and eating doesn’t count. Ok, a little extreme, but maybe not.
Finding the middle ground and the right shade of gray is a big part
of the learning curve.
The discipline with this approach rests with the assumption that
most of us know at any given time what needs doing based onour
circumstances at that moment in time and space. I suspect in
“recovery-speak” this translates to “doing the next right thing.”
Again, sounds simple doesn’t it? Unfortunately, simple doesn’t
always equal easy. Sometimes restraint and doing nothing is the
next right thing and other times doing what we need to do despite
our discomfort is called for. We usually know what our truth is, but
that doesn’t mean we have to like it.
Triggers and the Paula GoldbergTheory
“Feelings fade over time unless re-stimulated”
One of the primary laws pertaining to the human memory is that
feelings and memories diminish in intensity and frequency unless
they are re-stimulated. It’s one of the most important principles
within the context of Constructive Living we spoke about earlier. I
thought I would let you in on how I remember this law and how it
can apply to your recovery. And yes, it’s another story from my
very distant past.

85. 73
The dateline is eighth grade at Lawrence Junior High School
somewhere in New York. I am about 14 years old and suffer with
what was, at the time, referred to as juvenile onset obesity. In
other words I was a compulsive eater who was twice the size of
what would be considered “normal” for a 14 year old. So nowinto
the classroom enters Paula Goldberg, a very “hot” looking 14 year
old dressed in a mini skirt and knee high boots. No doubt you get
the picture. Kind of like the scene from the “Go Daddy.Com”
commercial with the supermodel and computer geek in a lip lock.
Fast forward the movie and I began a “diet” of raisins, cottage
cheese, and diet soda for the next several months until I became
this rather good looking, “svelte,” high school freshman. Now,
eventually, I ask Paula out to the junior, then senior prom.
Throughout high school we were, as they say, an item.
Comes time for high school graduation and off to college. Now
we’re both about to go to different colleges. I figure it’s time for
me to “sow some wild seeds” and not limit myself to Paula. I figure
it’s time to break up with her. Here’s where it gets a little
interesting. I invite her to meet me at the Town Diner [remember
Harry, this is the same place].
So we sit down at the table and Paula says she wants to tell me
something. I tell her “I have something to tell you too Paula, [big
mistake here] but instead I tell her “you go first Paula.” Paula
proceeds to tell me “Marty, you know I care about you, but I think

86. 74
we should take a break from each other and see other people.”
It felt like a dagger was plunged through my heart. Within an
instant my thoughts were: “How could she do this to me? This is
all a big mistake. Doesn’t she know how much I love her? Why is
she breaking my heart?” Here I was about to be the windshield in
this scenario and I end up being the splattered bug instead of her.
This is not right. This can’t be happening to me.
Now it’s Friday night, in fact it’s every night. I’m listening to all of
“our songs,” staring at all our pictures, her letters and cards,
driving past her house and calling her on the phone and hanging
up, and on and on. Carrying her picture for months and asking
everyone and anyone who knows her for the latest news release. I
see a strange car in her driveway and think it’s half the football
team from high school hanging out in herbedroom.
Anyone care to guess what’s happening every time I stare at her
picture, call and hang up after hearing her voice, search for songs I
associate with our time together? Yep, “feelings fade over time
unless re-stimulated.” Staying stuck is about re-stimulating the
pain by repeating the behaviors over and over again. Likewise, if
we don’t re-stimulate desired and appropriate feelings, our good
feelings and relationships also can suffer. Loving someone will fade
over time unless we repeat loving behaviors over time. Now how
does this apply to an eating disorder?

87. 75
Some of the actions that tend to re-stimulate eating disorder
feelings, thoughts, and behaviors need to be addressed.
Sometimes we call these triggers.
Using the bathroom scale is a good example of an avoidable
trigger. Weighing yourself frequently will result in re-stimulating
the obsession with numbers and body image. Other examples can
include isolating from friends, spending too much time alone,
eating binge foods, drinking alcohol, refusing to buy comfortable
fitting clothing, going on strict diets, reading fashion magazines
and comparing yourself to the models. The list is almost endless.
The point is to know the triggers you can avoid or eliminate, and
plan for those that you can’t control without acting on the feelings
and thoughts triggered.
In the end, there are some people with whom we want to re-
stimulate feelings and others we need to let go of. There are some
behaviors we want to avoid and others we want to reinforce. There
are times when we need to remember painful experiences so as to
avoid falling prey to the same problem. When you keep this
concept in mind you are able to guide your actions in the direction
you want your attention to go rather than be a victim of
unintended consequences.
To make the point, here’s a version of a three-chapter book on
relapse and recovery that goes something like this:

88. 76
Chapter 1:
I’m walking down the street and I don’t notice the hole in the
sidewalk and I fall in it.
Chapter 2:
I’m walking down the same street the next day and I see the hole
this time, but fall in it anyway.
Chapter 3:
I walk down a different street.
Of course, there are a few of us who’ve been accused of re-writing
this book and adding a 4th chapter in the relapse version.
Chapter 4:
I walk down a different street. I don’t see a hole, so I start digging
one.
Let’s leave Chapter 4 for another time. Hopefully you get the point.
There is an old adage that if we don’t remember our history then
we are doomed to repeat it. The "Paula Goldberg” rule is
remembering history and knowing when to re-stimulate stuff that
serves our recovery and let go of the garbage that tends to drag us
back into the abyss of addiction and despair. Farewell Paula.

89. 77
So What? Now What?
“Move a muscle, change a thought”
So, if an inability to get in touch with your true feelings and freely
expressing them isn’t the root of the problem and repressed
memories aren't it either, just what then is the problem? So glad
you asked. The true nature of the problem, especially with respect
to addictions has to do with almost total self-absorption and self-
consciousness. If you think about it, no pun intended, most of our
struggles have to do with repetitive and obsessive self-centered
thoughts. This self-centered focus is referred to throughout 12-
Step literature as a root cause of our suffering. Getting “outside
our own heads” by changing our behavior rather than obsessing
via “re-cycle-analysis” of past events and over thinking about our
feelings has its rewards. I’ve heard it said: “I may not be much, but
I’m all I think about.”
Just to recap, psychotherapies began with the notion of unveiling
and coming to terms with repressed memories and feelings. Later
schools of thought began to incorporate concepts such as
“cognitive restructuring” or retraining the way in which someone
sees things or what they may tell themselves. Others placed
emphasis on “getting in touch with feelings” and expressing
emotions as they reach a level of awareness. Kind of, “if it feels
good do it” or “letting people know how you feel.” To be fair, most

90. 78
professionals do suggest a measure of caution and social judgment
instead of “letting it all out.” However, I believe those approaches
that emphasize feelings at the expense of accountability hold
limited value in the recovery process.
Even if we can’t stay out of our own way with our obsessive
thoughts about our feelings or how we see ourselves, we can still
do the dishes, prepare the meal, listen to a friend’s problem, take
out the garbage, and so on. Chances are when we engage indoing
what’s in front of us that needs doing, we may briefly get outside
ourselves. Even if we don’t, we still have clean dishes and are rid
of the garbage in the kitchen.
By concentrating on what we need to do and engaging with right
behavior, we begin to have experiences, perhaps glimpses in the
beginning, of getting a respite from our obsessive thoughts. The
end game of a Constructive Living approach is the same as it is with
a 12-Step program – to gain freedom from our habitual patterns of
self-destructive behaviors and reclaim ourlives.
In the service of trying to simplify the differences between the
most widely employed therapies today, I would refer you to the
illustration on Table 3.1. Each string represents the sequence of
what needs to happen first and what follows. The last chain with
behavior taking the lead is, in our experience, the most effective.

91. 79
TABLE 3.1 – Behavior First
FEELINGS THOUGHTS BEHAVIOR CHANGE
THOUGHTS FEELINGS BEHAVIOR CHANGE
BEHAVIOR CHANGE THOUGHTS/FEELINGS CHANGE*
* CL / Milestones Approach
In Other Words -”Easy Does it….But Do it”
Have you ever felt tired and irritable and had the thoughts, “going
to school, or work, or a meeting or exercising won’t do any good,”
and ended up doing it anyway? Did your thoughts and feelings
change after? Did you regret having done the work or expending
the effort? Most people don’t complain after they’ve exercised or
finished their homework or finished their degree.
What is being suggested is simply that, although not a guarantee,
there is a good chance doing what needs doing will result in
changing your thoughts and feelings in a positive direction. Some
CL sayings go along the lines of: “If you want to feel healthy, do
healthy things.” “If you want to experience courage, you need to
do courageous things.” “If you want to experience recovery, you

92. 81
need to do recovery.” By doing so, your perceptions and thoughts
are likely to be reshaped and indirectly influenced by your actions.
You can again accuse me of butchering another famous quote by
restating it as follows: “I think I am, therefore I am” might be better
stated as “I do, therefore I am” – from that perspective, we tend
to be defined by what we do and not so much by what we say or
feel. Another cliché popular within recovery circles is “we are
judged not so much by our intentions as by our actions.” I know
very few people who get in trouble for what they think or feel, but
plenty who get into issues for what they do. Conversely, proper
action can produce amazingly good results in spite of feeling and
thinking negatively. More than likely the negativity will change
over time if the behavior is positive.
Being realistic about this “just do it” discipline is important. Doing
what needs doing does not always guarantee feeling good or
getting rewarded in accord with your expectations. Here’s a case
in point. I remember trying to put these concepts into practice
some time ago and came home one day to find a bunch of dishes
in the sink that my wife had yet to clean. Ok, I’m [feeling] resentful
that I’ve worked all day and here are dirty dishes that need to be
washed and [I think] my wife is supposed to wash the dishes.Alas,
I am now Mr. CL and will put on my CL outfit and wash the dishes
despite feeling crappy and resentful. Now that I’ve done the dishes
I am expecting my wife to be so overcome with gratitude that she’ll

93. 80
shower me with love and affection. Not happening. What I am
guaranteed by doing the dishes is clean dishes.
Perhaps a seemingly silly example, fact is you can control what you
do and maybe influence how you then feel and think. However,
you have little control over the rest of the universe. The purpose
of developing the discipline, or habit if you prefer, of doing what
needs doing as each situation presents itself, is not meant to
always be directed at fixing a feeling. Instead, it is intended to build
a manner of living that is commensurate with recovery and, as
such, offers the most possibilities of minimizing self-inflicted
problems and increasing the quality of daily living. It promises not
to always be a means of feeling well, but instead a means of
learning to do well. Obviously, doing well eventually leads to a
much better batting average of positive thoughts, feelings, and
experiences – especially when you’re able to deviate from an
obsessive focus on yourself in the process.
The following is an excerpt from an earlier article I wrote to
summarize some of the ideas we’ve been talking about here.
Forgive me if some of what you are about to read seems repetitive.
“Much energy is expended in the service of helping people here
explore the full texture of their emotions and beliefs.
Acknowledging our feelings and our thoughts are important.

94. 82
Whether expressed or restrained, both need to be recognized and
accepted rather than denied. In fact, when our feelings and beliefs
are pushed aside and not acknowledged we may be prone to taking
actions that are not always in our best interests. The problem arises
when one believes it necessary to understand the cause of our
feelings as a prerequisite for being able to change. Knowing the
why of our feelings is not as important as knowing what it is we
need to do in response to what’s happening in a given moment. I
need not know why I’m nervous in order to walk in front of the
group and give my presentation. I don’t need to understand why
I’m feeling shy around this person in order to initiate a conversation
or ask them out for dinner. Feeling angry, I can still make the bed
and clean my bedroom. Being afraid to fly need not stop me from
buying a plane ticket and visiting my friends. Presentations are
given, social engagements are made, rooms are cleaned, and trips
are taken despite the feelings and thoughts. Doing what needs
doing does not guarantee to “fix our feelings”. It does guarantee
we get done what we need to do without being debilitated or
controlled by our emotions and thoughts. The payoff, if you will, is
huge.
Consistently practicing this discipline diminishes our fear of
experiencing all the emotions and thoughts we’re capable of
having. In other words, we need not avoid our feelings, but can
acknowledge them, accept them, and not have to be ruled by them.

95. 83
A way to view all this is to realize we can develop control over our
behavior and not be limited by our fears, emotions, and obsessive
thoughts. Most importantly, we can eliminate the need to self-
medicate feelings as we come to accept them rather than insist
they be changed because they are unacceptable to us. We begin to
realize our feelings and thoughts will not destroy us. Our feelings
will take care of themselves over time if we no longer allow them
to govern all our actions. Progress is best measured in terms of how
we’re doing rather than how we’re feeling over any given period of
time.”
Control Issues
“God grant me the serenity to accept the things I cannot change,
the courage to change the things I can, and the wisdom to know
the difference.”
Of course the catch phrase is the “wisdom to know the difference”
part. Truth be told that can be a sticking point for many of us.
Knowing when to “let go” and when to “try, try again” takes a little
self-honesty and humility. Perhaps a beginning principle here
might be admitting our limitations. It’s human nature to want or
demand we be able to control stuff. The problem arises when we
insist on controlling what is either uncontrollable or directly
clashes with the control needs of someone or somethingelse.

96. 84
Controlling your weight by starving yourself puts you in conflict
with your body’s need to control its' health. Your body doesn’t
sympathize with your cosmetic or body image concerns. Typically,
what starts out as you controlling something like food, drugs,
weight, other people’s feelings or behavior, and so on ends up with
“it” controlling you. An integral piece of the ABA text* suggests
most people who suffer with anorexia, bulimia, or a relatedeating
disorder harbor intense issues with control and trust. It would
seem the focus on control eventually works its way down to a
reliance on self-medicating with food or starvation. Trust becomes
a matter of not even being able to trust oneself, let alone anyone
or anything else.
If you were to look closely at those having the most success with
recovery you’ll likely see they’ve found a way to let go of control
when appropriate and to trust something or someone other than
their “self-will”. It’s been said addictions are “diseases of
perception” and in no other instance have I found that more to be
the case as with an eating disorder. It’s helpful to remind ourselves
where our “best thinking” has taken us.
Proper use of control, namely taking “right actions” and following
a set of prescribed recovery behaviors – treatment that includes a
food and exercise plan, proper rest, and developing your own
sense of spirituality - is within your control. Trying to constantly
control what you feel or think is exhausting and really doesn’t work

97. 85
for very long. Furthermore, most of us have an overwhelming
tendency to “over think” and “under do”. The formula usually
comes down to “over analysis leads to paralysis.” I can assure you
no one has recovered from any addiction or eating disorder
without changing the addictive behavior first. Control what you do
and waste as little energy as possible trying to control everything
and everyone else.
Last, but not least, keep in mind the notion of middle ground and
how it applies to the need for some of us to refrain from over-doing
and perfectionism. There is both the need to act despite our
feelings, as well as, the need to employ restraint and not do at
times. Being honest with yourself will go a long way to know what
needs doing in the service of your recovery and not yourdisease.
**********
The Foundation of Recovery – S.E.R.F.
“Read something to someone and they’ll likely forget it, show
something to them and they may remember it, have someone
experience it and they will come to understand it.” – Buddhist
Proverb

98. 86
With few exceptions, the human mind will retain a very limited
amount of information unless there is some emotion or experience
attached with it. As it applies to eating disorders, having
experiences with new behaviors around eating, as well as,
experiencing self-care serves us better than intellectual
knowledge. There’s no shortage of dietitians, therapists,
physicians, and such who come to us looking for help with an
eating disorder. Knowing and doing are two entirely different
things. Once again, doing, becomes understanding while
intellectual knowledge alone is just that, knowledge without
benefit.
Now we come to the use of slogans and acronyms that arehelpful
to us mortals and remind us of the basics of recovery. I’ll spare the
reader most of these, but tell you one we’ve come up with at
Milestones. It’s an acronym representing the four essential parts
of recovery from an eating disorder namely, spirituality, exercise,
rest, and a food plan - S.E.R.F.
Some time ago I put together a brief article outlining what I believe
to be among the most important ingredients in a long-term
recovery recipe. What follows is an excerpt of the article I
published that also appears on the Milestones Website.

99. 87
“There are a couple of assumptions I have regarding the basic
building blocks necessary to build a solid foundation in recovery.
Let me be candid again and put out there one of the more
important ones begins with a total commitment to being consistent
with what we do on a daily basis. This means no matter what we
are feeling, what “tricks” our minds play on us, or what life
surprises us with, we still can control our behavior and be
consistent with what we do despite this. The “first things first”
slogan suggests self-care as a priority. To do otherwise leaves us in
no condition to take care of anything or anyone else. “Placing your
oxygen mask on first before helping the person next to you” is not
just sound advice in the air.
From this standpoint, maintaining a prescribed food plan,
adherence to a moderate schedule of exercise, finding and
maintaining a healthy balance between work, rest, and play, and
cultivating your own brand of a spiritual connection are the basics
– in other words the building blocks in recovery are S.E.R.F.
Now for the tough part that separates a recovery program from a
“diet program” disguised as recovery. Like most addictions and
illnesses that center on our need for CONTROL, all eatingdisorders
have in common the obsessive focus on the goal of total control of,
in this case, eating, body weight and body image. Letting go of
control from a recovery standpoint is not about “giving up” but

100. 88
rather following a prescribed program (as noted above) and letting
go of the outcome – namely not making changes in response to
feelings, fears, or temporary changes in our bodies. Allowing
someone other than us, at least in the beginning, direct our food
and exercise plans is a far more objective and ultimately successful
means of finding a solution to the mental tyranny of trying to do it
alone. To be sure, it takes a quantum leap of faith and courage to
“turn over” control to someone other than yourself. In the end,
sponsorship in an appropriate support group such as OA or ABA,
making good use of a trusted and experienced professional, and
cultivating a belief in your own understanding of a higher power
will put you on the path to reclaiming your life”.
Marty Lerner, Ph.D.
It’s All About the Food…Isn’t it?
A food plan is not meant to be a “diet” in the traditional sense of
the word. It is better viewed as akin to comfortable clothing rather
than a straightjacket. It may change and be adjusted over time and
is not a “quick fix” or the be all and end all to treating an eating
disorder. However, it is an integral piece of the recoverypuzzle.
Although the term abstinence refers to the cessation of eating
disordered behaviors, whether binge eating, restricting, purging,
and so on, it also can refer to the specific boundaries regarding
properties of foods [types and amounts] within the plan. In

101. 89
essence, an “abstinent food plan” is one that suggests eliminating
junk foods, as well as, accounting for portions.
At Milestones abstinence refers to “clean” eating by keeping sugar
derivatives* to no more than the fifth ingredient in any food
product, avoiding most refined flour products, and steering clear
of highly processed junk foods, as well as, being mindful of portion
sizes. With regard to volume, when all is said and done, eating
disorders carry with them a tendency to either over or under
estimate amounts of food eaten or suggested as part of a meal
plan, hence, the recommendation to weigh and measure portions
as part of the experience here. Doing so can be reassuring to the
person fearful of eating “too much” and helpful to those needing
a “reality check” on the volume / amount of food on their plan. It
is intended as a teaching tool and to not “morph” into another
compulsive behavior like calorie counting. Weighing a portion of
chicken or tofu should not be performed as if calculating the
atomic weight of a protein molecule. Likewise, “tossing” an entire
package of cheese on a food scale and rounding off to the nearest
pound, then placing it on your plate is also not in the spirit of
measuring a portion. Once again we need to recognize someneed
to be a little more compulsive, while others need to lighten up a
little bit. Feast or Famine, Black or White, Pass or Fail, All or None
– we must find a balance in the middle with our food relationships.
In fact, our approach to eating is probably a metaphor for our

102. 91
overall approach to living. Working with an experienced dietitian
and crafting an abstinent food plan that evolves into an
individualized plan over time, is key to finding this middle ground.
Within a given set of guidelines there is room for individualized
plans and differences. One size does not fit all with abstinentfood
plans. People will vary with reference to food preferences and the
amounts needed to meet their nutritional needs. It is similar to
what needs doing with exercise plans.
*Sugar derivatives refer to table sugar, corn syrup, dextrose, and
any number of processed products that are chemically equivalent
to sugar and its effect on the body.
To Weigh or Not to Weigh, That is the Question…
Perhaps a somewhat debatable issue is whether we should weigh
ourselves during the course of treatment, as well as,“ever after.”
My vote is a resounding no. The bathroom scale has either been a
source of despair or used as an “addictive tool”, dictatingwhether
one feels good or bad. Worse yet, it usually progresses to whether
one is good or bad. Perhaps it's better to have a trusted
professional or sponsor, at least during the initial phases of
recovery, monitor our weight for us. Taking a “blind weight” can
help break the vicious cycle of compulsive weighing. Some have
taken the opposite tack and historically avoided the scale

103. 90
altogether, although perhaps initially for the wrong reasons, such
as denial. I would still encourage people to refrain from “scale
dependency.”
Better to concentrate on following a reasonable food plan and
practicing the S.E.R.F. formula as a measure of progress, rather
than the number showing up on a bathroom scale. The reason is
simple – the body will take care of itself if we are treating it
appropriately. Cosmetic concerns aside for the moment, the body
will react by finding an appropriate “set point” over time. The set
point may reflect either an increase or decrease in body mass
depending on what “the body needs.” It may also remain static if
the BMI is not a primary symptom of the eating disorder. I would
remind the reader, not all binge eaters are overweight and not all
those suffering with Bulimia are significantly above or below a
reasonable set point. However, if binge eating or restricting has led
to the “symptom” of being over or under a healthy body weight,
then following a reasonable food plan will “right the ship” and
bring the body into balance by restoring a reasonable bodymass.
The gap between what is a healthy set point and what ones’
perception of what “looks good” may be a matter of a body image
issue and not a betrayal of your body. The cosmetic norms have
changed as frequently as yesterday and today’s fashion trends,
while the biological norms have not really changed in the past
several thousand years. So, the effort needs to be placed with

104. 92
“SERF” and not with manipulating the body to reflect a certain
number or conform to the body image du jour. The “trust” and
“control” issues we spoke about before have to do with trusting
your body’s response to a healthy food and exercise plan and
letting go of trying to control your body’s set point at any cost.
The measuring aspect of recovery as it relates to the food plan is
to weigh and measure our food and not our bodies. Doing so
avoids the tendency to over or under do what’s called for on our
food plan and serves as a teaching tool. It is not intended to
aggravate our compulsive nature, but rather to focus on following
a part of our recovery plan. Whether one continues to do so after
a few weeks or months of recovery becomes an individual choice.
Perhaps the same can be said for being weighed periodically by
yourself or someone else. If the benefits [excuse the pun]
outweigh the negative effects, fine. For most people, relying on
other measures of what’s happening with our bodies such as how
our clothes are fitting, etc. are enough.
Measuring Recovery – How am I Doing?
This is a really short topic. I would encourage anyone with an
eating disorder, or any addiction for that matter, to measure
progress in terms of how one is doing rather than how one maybe
feeling at a given time. Quite frequently, we may be feeling bad

105. 93
while doing very well and vice versa. Eventually our feelings “catch
up” to our actions over time. This “double edged sword” can cut
both ways. Best to place your bet on doing well and chance that
the feelings will soon follow.

106. 94
Chapter 4:
Maintaining your Recovery

107. 95
S.E.R.F. Lessons
Let’s see how many metaphors we can come up with for the SERF
stuff. “Stay close on your SERF board or you might drown.” Ok, ok,
how about – “The key to SERF-ing is all about balance” – I likethat
one. I’m done. Thanks for indulging me.
Spirituality – Give me an “S”
A quick disclaimer, I am no guru or authority on the subject
of spirituality. In the context of eating disorder recovery Iwould
suggest spirituality is, however, an integral part of ongoing
recovery. Defining spirituality is, at best, ambiguous. That may
be a good thing since there are no rules or religious dogma
attached to its practice. It affords anyone and everyone an
opportunity to participate. So let me attempt to bring together
two concepts that permeate the 12-step addiction recovery
literature – spirituality and powerlessness.
First, allow me to quote from Elisa Goldberg’s workbook used as
a text for her course on Spirituality in Behavioral Health Care
Settings [Drexel University -October, 2013].
“Spirituality is an essential element of human experience. It
represents the part of us that searches for meaning, seeks out

108. 96
transcendent experiences, and recognizes that a force exists
beyond the material world. Spirituality encourages hope and
purpose. It can foster positive emotions, coping skills, and
recovery in the face of behavioral health challenges. Although
many important spiritual resources come from religious
practices, spirituality and religion are not the same. Research
has shown a multitude of connections between having faith and
living well with behavioral health challenges, yet most
professionals have little training in the area of spirituality.”
Although there is probably more confusion about the meaning
of “powerless” than just about any other term in the addiction
literature, it really is quite simple. “Powerless” refers to the
addict’s, in this case someone with an eating disorder, being
unable to stop and stay stopped on one’s own willpower. Let
me run that by again. Being powerless means, despite endless
attempts to control your ED on your own, the result is usually
a brief period of remission followed by relapse back to the ED.
The suggestion implied with this concept is to begin looking
for a “power greater than yourself.” Given the track record
of countless attempts to do it on your own this might not be
such a bad idea. This leads us to a discussion and perhaps a
conceptual understanding of spirituality.
Ok, what’s this “higher power” thing about? The ambiguous

109. 97
answer is, whatever you deem it to be as long as it is a
“power source greater than yourself.” Regardless of prior
experiences with religious organizations, spirituality begins
with a sense of humility and an awareness of the need to rely
on something or someone other than simply ones’ self. It may
initially involve a reliance on a group of people like a support
group, a 12-Step program, a community of peers at atreatment
center, a group of professionals, really just about anything
other than just you alone. Of course, it may be something
not human at all, such as a universal energy, or of course, aGod
of our own understanding.
The point is spirituality has to do with cultivating and developing
a relationship that involves a healthy dependency on a higher
power. It likely necessitates a daily practice reinforcing that
belief with a set of individualized behaviors that are in sync
with your concept of spirituality. It may or may not incorporate
any religious practices or prior beliefs. It belongs to you and
you alone. You define it and you use it as such.
The important part of this letter S in SERF is that it is practiced
on a daily basis. The doing part may include attending
relevant 12 step or other support groups, reading literature
relevant to your flavor of spirituality and values, helping
others, prayer and/or meditation, yoga, or anything that

110. 98
furthers your reliance/connection with that “power source.”
For what it may be worth, spirituality fosters the belief that
together with that source you can do for yourself what you
might not be able to do alone. How it works for you will depend
on how you proceed with the rest of the steps in a 12-Step
oriented recovery program or cultivating as an “add-on” to
either existing or a newly acquired set of recoveryskills.
An Exercise in Futility? – Give me an “E”
As mentioned throughout this text, eating disorders are
characterized by extremes in behaviors, emotions, and
perceptions. A kind of black or white, all or none, approach to
things is certainly part of the problem. So why should exercise be
any different? Coming in basically two flavors – compulsive over-
exercisers and under exercisers. Feast or Famine – where’d I hear
that before? Obviously, some need to increase their activity /
exercise while others need to cut back on the frequency, intensity,
or duration. So here again we need to speak in the language of
moderation and find a middle ground. Exercise in the service of
recovery is not a matter of increasing calorie expenditure, weight
reduction, or building muscle mass per se, although these may or
may not be by products. Exercise is meant to serve both body and
mind in the obtainment and preservation of emotional and
physical health. What a concept!

111. 99
Just as an aside, our bodies respond to excessive exercise and
activity [burning too much energy] with fighting for survival. It does
so by conserving energy. Thus, too much exercise and your body’s
metabolism will slow down in an effort to fend off starvation and
tissue loss. In other words, too much exercise and too little food
begins to demand more exercise and less and less food to maintain
continued weight loss or prevent weight gain. Anyone remember
what symptom of addiction this refers to? That’s right – it’s
TOLERANCE. Developing tolerance requires more of the same
behaviors or substances to achieve the same effect. I guess we
could say again this is about “getting caught in your own mouse
trap.” Likewise, the loss of a regular menses signals the body is not
able to withstand the rigors of child bearing while in survival mode
and protects itself by slowing down energy expenditure,
decreasing sex drive, and reverting the body back to an almost pre-
adolescent state.
With the “too little exercise” end of the spectrum, we are caught
up in the spiral of inertia. With an inadequate amount of activity
the body responds in ways that make it ever more difficult to dig
ourselves out of the hole we’ve dug. Our metabolism slows and
our energy levels decrease. We can find ourselves developing
metabolic diseases such as adult onset diabetes [Type II Diabetes]
with increasing insulin resistance. Our overall muscle mass

112. 101
decreases and we begin to associate feeling exhausted with
“thinking” we need to feed ourselves.
Moderate exercise is difficult to figure out objectively when in the
midst of an eating disorder. Like hunger perception and body
image, it can be confusing at best. With the amounts of food, we
tend to overestimate and under estimate what’s needed for our
recovery. It’s best to have someone with experience suggest a
reasonable exercise / activity plan along with a food plan in the
beginning. Individual needs will vary in accord with ones’ level of
fitness, their body mass, medical history, and so on. Suffice it to
say, moderate exercise should consider the following factors – for
example, frequency [3-5X weekly], duration [20-60 minutes],
intensity [60-80% of MHR]* may be guidelines.
*Aerobic intensity is usually measured by a formula that considers
someone’s age, max heart rate, etc. For our purposes, intensity can
be equated with being able to carry on a conversation while
exercising without losing your breath.
Rest – The Balance between Work and Play –
Give me an “R”
Ok, for some of us it may be “all work and no play” and of course
for others, "all play and no work.” The proper balance between
work and play is an essential piece of the recovery puzzle. I suspect

113. 100
the majority of people with an eating disorder fall within both ends
of this continuum at different times during the course of their
disease. Perhaps you’ve gone through a phase of “all in” on the
being productive at work or school bit and “burned the candle at
both ends.” The usual outcome has probably been like some of
our less than stellar relationships and projects – a spectacular
beginning, a somewhat boring middle, and a very dramatic
crashing and burning to the ground ending. Without finding a
balance with the integration of our recovery - meetings, SERF
activities, social relationships, work, school, play time - relapse is
just about certain.
Of course if the pendulum has swung to the all play or doing too
little side, then we can quickly find ourselves making our eating
disorder our “career” and a full-time job at that. Without a balance
and a sense of purpose beyond ourselves, most people with an
eating disorder will be destined to focus on controlling their
feelings with their eating disorder or some other related form of
self-medication.
Activity can also be part of the rest prescription. Misinterpreting
feeling tired and “thinking” we need to rest when, in fact, we’re
mentally stressed out and not physically tired happens all the time.
This is most often the case when our work or schedule involves
more of an emotional investment than a physical one. We

114. 102
interpret mental stress as physical stress and think physical
inactivity is in order. Indeed, what needs doing in this instance is
rest that involves activity and movement [aka exercise]. Physical
activity serves to balance emotional stimulation and intellectual
activity balances physical exertion. Physical work necessitates
physical rest while intellectual pursuits require physical activity to
restore balance. All this may sound confusing, but will make sense
after you experience it for a period of time. Whether a person
needs rest by intellectual challenges, physical activity, or play will
vary in accord with their circumstance and daily routines.
Last, but certainly not least, is sleep. Providing yourself with
adequate time to allow for 7-8 hours of sleep nightly is sound
advice. However, it should be mentioned that almost everyone
new in recovery has some difficulty with sleep – usually not able to
fall asleep and/or stay asleep. Sleep is one of the few behaviors we
have limited control over. Over time and with continued recovery
the sleep cycle rights itself and sleep follows a healthy and
predictable rhythm. During the initial part of your recovery you
may benefit from a non-addictive medication. Short of that, I
would suggest providing yourself with ample time to rest and, even
if not sleeping, begin the habit of being consistent with a time for
sleeping. If you are having a problem with sleeping at night, know
this will pass over time. Be careful not to nap or sleep during the

115. 103
daytime while your body is making adjustments to a sleep cycle in
sync with recovery.
Food Plans: Food for Thought – Give me an “F”
Rather than enter the “great food debate” and subject you to more
repetition of what has already been discussed, this section is
relatively short and [there’s that food pun again] sweet. The basics
[cooking pun now] boil down to eliminating sugar, flour, and highly
processed, high-glycemic foods, and controlling the volume of
food on the plan. There is also the suggestion of weighing and
measuring portions to insure accurate portions given the notorious
tendency among us to “distort” amounts.
I want to repeat once again and be perfectly clear the food plan is
not a diet, but a set of boundaries around eating. It is intended to
become a comfortable experience over time and not to function as
a set of handcuffs. The food plan is simply healthy eating,
eliminating junk foods, and insurance against either overeating or
under eating. It is subject to modification and adjustment under
the direction of someone other than you. It has an ability to be
flexible, but not at the expense of certain established boundaries.
Think of it as medication – something you neither prescribe nor
change without talking it over with the person responsible for
prescribing it in the first place.

116. 104
At Milestones we don’t place people on either extremely high or
low calorie food plans to achieve rapid weight gain or loss.
Milestones differs from most programs, in so far as, believing
people do better eating an amount of food that will eventually
sustain an estimated weight range or set point. Let’s assume for
the sake of illustration, a person enters treatment with a body
mass equivalent to 200 lbs. with 125 lbs. being an estimate of their
set point. That person would do best eating the equivalent amount
of food commensurate with a 125 lbs. person and not a plan
appropriate for a 90 lb. person. The same would hold true for a 90
lb. individual with a set point of 125 lbs., namely to follow a food
plan meant for a 125 lb. person and not a 200 lbs. individual. There
shouldn’t be a race to lose or gain weight as quickly as possible.
The goal is learning through experience how to live comfortably
within your set point. There is no “finish line.” This should be
happening during and after treatment. You do not want to finish a
program with only the experience of eating like a 200 lb. or 90 lb.
person and suddenly expect to amend your food plan afterwards
to some “maintenance plan.” Over-feeding or under-feeding in a
treatment program tends to reinforce the problem rather than
offer a longer-term solution. As noted earlier, progress is not solely
a matter of a rapid change of the number on the scale.
As a general rule, the food plan considers volume and caloric intake
from the standpoint of the long-term picture. As mentioned

117. 105
earlier, the focus needs to be on healthy and appropriate eating
not on rapid changes in body mass. The body will self-correct over
time if it is not treated with extremes or abused. A reasonable food
and exercise plan should be designed with this in mind. The guiding
principle here is to find a means of establishing a long-term
relationship with food and not a dramatic, chaotic one.
*The specifics of a food plan beyond the basics of weighing and
measuring portions and eliminating non-abstinent foods is left to
the program’s dietitian and that person to sort out. Participants
at Milestones are able to choose what their food preferences are,
design, plan, and prepare meals in accord with the food groups
and portions they agree upon with the dietitian. In effect, there is
a balance struck between what is nutritionally needed to
establish and sustain an abstinent food plan and resultant
healthy body. Whether vegan, vegetarian, or some other
variation, there is the ability to find a food plan that will work
within the bounds of recovery.
To be sure, it should be said there exists a small group of people
who come to the point of needing a more aggressive approach to
re-feeding or quick weight reduction. Again, one size does notsuit
all. Inpatient and hospital based settings with forced feeding and
strict monitoring, as well as, surgical interventions like gastric
bypass procedures, do have a place in the eating disorder

118. 106
treatment world. The program at Milestones is not intended for
such interventions. For those unfortunate enough to have
progressed to that stage, more intrusive measures are necessary.
Indeed, the physical consequences of their illness have become life
threatening and demand a higher level of care than a residential
program can provide. It is a topic for discussion going beyond the
scope of this one.
Basic Tenets of a Recovery FoodPlan
Rather than begin with the typical list of menus and foods one
might find in a "diet" book, I thought it best to review some of
the basic principles and operational definitions inherent in a
recovery food plan. I might also add, that these principles
would easily enhance the health and well-being of anyone
following most of these principles and suggestions. Last, but
not least, I would encourage anyone considering following
what we will now term a "clean" or "abstinent" food plan,
consult a registered dietitian familiar with the treatment of
eating disorders, as well as, experienced with addiction.
What follows is a list of the essential elements forming the
foundation (basics) of clean eating for those recovering from an
eating disorder:

119. 107
• Highly processed, high-glycemic foods (e.g. sugar/refined
flour/trans fats) should be eliminated or avoided as much
as possible.
• Portions should be weighed and measured so as to avoid
over or under estimating portions. The principle behind
this suggestion is not in the service of reinforcing counting
calories or weight, but rather to eliminate the tendency to
over or under estimate portions.
• Consideration should be given to choosing a variety of
different foods within the bounds of the food plan rather
than getting stuck in rituals or patterns of eating thesame
meal repeatedly.
• Eating at regular intervals throughout the day - not
allowing more than 4-6 hours elapse between meals
and/or snacks. The principle here is to not get too hungry.
• With respect to quantity of food (caloric intake) servings of
proteins, complex carbohydrates, and healthy fats should
take into consideration an individual's "set point" or
healthy weight and not reflect rapid changes in body
weight. For example, if an estimate of healthy body weight
is 125 lbs., a food plan should reflect the set point
regardless of whether someone is significantly above or
below a healthy weight.
• Consideration should also be given to activity/exercise
levels that reflect exercise and activity in the service of

120. 108
recovery and not in the service of reinforcing eating
disordered behaviors. It is best to have a dietitian or eating
disorder specialist consult on exercise, as well as, food
plans.
• Individual responses and "sensitivities" should be given
consideration with respect to the use of artificial
sweeteners, caffeine containing beverages, and other
foods and beverages that are "triggers" to overeating
and/or producing changes in appetite.
As mentioned, the list is intended to present a broad stroke of the
basics making up a sound and healthy whole food plan. With
respect to the restricting end of the eating disorder spectrum,
experience has demonstrated the need to reinforce adequate
amounts of "clean food" and discourage the tendency to distort a
food plan as a restrictive diet in the service of preventing or
promoting further weight loss. Likewise, the "weighing and
measuring" principle can serve to "reassure" someone they are not
overeating and instead, following a prescribed plan to restore their
body back to health.
Worth mentioning is the notion a food plan is not a diet. For most
of us, a diet represents a temporary restricting of caloric intake via
some combination of foods and/or exercise in order to lose weight.
A food plan, in this case a "clean eating plan" is not meant to be
temporary. It is intended to transform the individual from having

121. 109
an addictive relationship with food or dieting to one that is
followed by choice rather than compulsion. In the end, itbecomes
a part of recovery that one incorporates into a lifestyle, free from
the tyranny of an eating disorder. The guiding principle of a food
plan is that it fit like a comfortable set of clothing and not be
experienced as a straightjacket. In the last chapter of this book
there are examples of abstinent recipes for your perusal.
Healthy Relationships – The 4 A’s
One of the more challenging aspects of recovery is learning to
navigate through our relationships with family, friends, and co-
workers. One certainty exists for people regarding their ongoing
relationships prior to entering recovery is that; no relationshipwill
stay the same once they begin recovery. It’s not unusual for people
who care about us to want our eating disorder to end, but aren’t
necessarily prepared for the other changes that usually follow.
These can include becoming more independent and leaving us less
dependent on those who are used to being the decision makers.
Now we demand a “voice” in our relationships and assert
ourselves, and set new boundaries and limits with our significant
others. These may be a few of the more obvious changes, but there
are many subtle “shifts” in our personalities as we emerge from
the ashes of self-hate and isolation. Sometimes in a family or social
network we find our acts of independence can be looked upon as
acts of betrayal. We experience resistance to some of these

122. 111
changes as we begin to become more true to ourselves. In effect,
it’s important to anticipate many of our relationships will undergo
“growing pains” with the result being either a permanent parting
of the ways, or a temporary distancing. Often, a coming back
together with a newly defined, healthier relationship will evolve
over time. Although no one is really the ultimate authority on
relationships, here are the essential elements necessary for a
healthy relationship.
The Four A’s of Relationships:
1. ATTRACTION
2. AFFLUENCE
3. AVAILABILITY
4. APPROPRIATENESS
Attraction refers to the physical and personality traits of a person.
What is it that makes us attracted to someone? Character,
personality, appearance and any number of traits can be part of
the equation. Attraction can refer to sexual and non-sexual
relationships. We can be attracted to a friend’s sense of humor, a
teacher’s wisdom, and so forth.
Affluence not only refers to a person’s finances but, more
importantly, their ability to be self-supporting and self-sufficient.
Being affluent in a relationship has to do with wanting to be with

123. 110
someone rather than needing to be with someone. It also
represents an ability to think for ones’ self and not be unduly
influenced by the opinions of others.
Appropriateness is characterized by exhibiting acceptable
behaviors in the context of a given situation. What may be
appropriate behavior or language in the locker room may not be
the best for the dinner table, etc. Being appropriate is exercising
sound social judgment.
Availability is about being both physically present, as well as,
emotionally present. Someone who is physically present, but is
emotionally distant is not someone who is available. People who
are active with an addiction, such as an eating disorder tend to be
unavailable. Physical and emotional presence is necessary for
someone to fulfill the criteria of availability
4 A’s – And the Point Is …
When examining our relationships, we might consider whether the
person or persons who are important to us exhibit these 4 A’s. If
not, which are missing? Whether we would like to admit it or not,
most relationships falling short of any one of these are apt to be
problematic. Sometimes we find the problem is with someone in
our family, perhaps a parent. In such instances we are bound to
experience the stress involved with redefining the relationship on
our end. The key to this is accepting the fact that we’re unlikely to

124. 112
change others. However, we do have the ability to change
ourselves. This brings us to an important point*.
The point is to not insist on finding someone who makes the grade
or trying to force someone into becoming our version of these
attributes. The real challenge is becoming the4As.
Relationships in Recovery – “Rules of the Road”
- Water seeks its' own level when it comes to relationships. In
other words, “birds of a feather tend to flock together.” Stick with
the winners in recovery.
- Relationships do not remain the same when one or both people
in a relationship begin recovery. There is a shift in the balance of
power.
- Often acts of [responsible] independence can be perceived as
acts of betrayal when new recovery behaviors begin to emerge.
- As recovery progresses, the tendency is to trade in approval for
respect from others – aka people pleasing decreases and
assertiveness begins to replace it.
- Priorities start to shift in recovery. The need to control others
starts to diminish over time.
- The experience of walking into a room full of people and
wondering “who is going to like me” starts changing to “who do I

125. 113
think I might like here?”
- Dropping the idea of needing to be needed in order to feel
secure in a relationship. Allowing others to take responsibility and
make their own mistakes. Staying in a relationship based on choice
rather than need.
- Looking at “your side of the street” rather than habitually
focusing on the other person’s faults or defects. Self-inventory
first.
- Becoming less tolerant of unacceptable behaviors from others
such as abuse or active addictions. Setting boundaries.
- As mentioned, placing your energy with becoming the four A’s
rather than trying to find or control someone to make them into
the four A's.
- Staying “in your own lane.”
There are times when you may find it helpful to look at these
attributes in relation to places and things and not just people in
your life. Take a look at yourself along these lines with a job,
school, your recovery program, your support group, your clothes,
and so on. In each of these you can ask yourself whether you are
attracted to or attractive, as well as, affluent, appropriate, and
available. Very often, you’ll find a direct link between how we’re
behaving with “things” and “places” and our relationships with

126. 114
people. Perhaps something to give a little thought to - but then
take action with. The 4 A checklist can give you a general idea of
just how you’re doing "and what still needs doing.”
Compliance vs Acceptance and Surrender
A frequently overlooked phenomenon within the recovering
community, aka 12-step oriented fellowships, is a true
understanding of the subtle difference between being compliant
and truly accepting ones’ “addiction.” A growing number of
professionals, not to mention the recovering community at large,
have long understood addiction is a disease with a common set of
symptoms and characteristics. In most instances these symptoms
are both psychological and physical in nature. Whether we’re
speaking of alcohol, drugs, compulsive gambling, or the different
manifestations of disordered eating [inclusive of compulsive
eating, binge eating disorder, bulimia, or anorexia] they all sharea
similar sort of “DNA.” I would refer the reader back to the
professionals charged with defining the symptoms of an addiction
outlined earlier in this book in Chapter 1. Formulated by the
American Psychiatric Association’s Task Force on Addiction, the
consensus stands today as the “Gold Standard” for diagnosing
addiction. In effect, this is one way of restating the difference
between a bad habit and an authentic disease entity.

127. 115
Should we look beyond the substance, or for that matter most
compulsive behavior[s], we begin to see what separates those who
enjoy long-term recovery from those who tend to repeatedly
relapse. In other words, exploring the nature of the person and not
simply the nature of the substance or behavior. What follows
comes in large measure from the original works of Harry Tiebout,
M.D., and William Silkworth, M.D. Both men were pioneers in the
field who treated countless numbers of alcoholics and addicts.
Each understood the physical and psychological aspects of
addiction and, in their own way, shed light on what makes
someone suffering with an addiction different from their non-
afflicted peers.
Compliance, Acceptance, Surrender - A Process, Not an Event
Let me begin by clarifying these concepts and elaborating upon the
practical implications of each of these states of mind. Let’s begin
with the notion of compliance. To paraphrase Dr. Tiebout,
compliance refers to an individual “agreeing, going along with, but
in no way implies enthusiastic, wholehearted approval”. Usually
there is a willingness not to argue or resist and although
cooperation exists, it comes with some reservations. In other
words, one is not entirely happy about agreeing or following “the
party line.” The willingness to, let’s say abstain from certain foods,
drink, or substances is somewhat shaky. Suffice it to say it doesn’t

128. 116
take much to shift from compliance to relapse. Although the good
doctor speculates this is an “unconscious” phenomenon, I would
disagree. Most people in early recovery have some very conscious
reservations about their “lack of power” [aka lack of control] and
insist on stepping back into the ring after a brief period of
remission. Perhaps we can say compliance is a close cousin to
denial.
Understanding the specific dynamics of acceptance is tantamount
to understanding what separates those with long term recovery
from those who experience only brief periods of recovery.
Continuing with Tiebout’s observations:
“Acceptance appears to be a state of mind in which the individual
accepts rather than rejects or resists: he is able to take things in, to
go along with, to cooperate, to be receptive. He/She is not
argumentative, quarrelsome, irritable or contentious. For the time
being, at any rate, the hostile, negative, aggressive elements are in
abeyance, and we have a much more pleasant human being to deal
with. Acceptance, as a state of mind, has many highly admirable
qualities, as well as, useful ones. Some measure of it is greatly to
be desired. Its’ attainment as an inner state of mind is never easy.”
– Harry M Tiebout, M.D.

129. 117
In my experience the transition from compliance to acceptance is
a process rather than an event. As such the period of time from
which a person moves from a compliant stance to an acceptance
state of mind varies greatly. However, I would add to Tiebout’s
thesis, getting from point A to point B is quite similar to what we’ve
come to understand as the stages we all go through upon suffering
a loss. [On Death and Dying: E. Kubler-Ross, 1969]. Letting go of
our primary “reward” or “feel good” thing is no easy task. To be
sure, it is a great loss if you suffer from the disease of addiction.
The experience of transitioning to acceptance, and to that of total
surrender, will encompass the following stages:
DENIAL
ANGER
BARGAINING
DEPRESSION
ACCEPTANCE
As with other losses, one can expect to negotiate these in a
sometimes back and forth pattern, vacillating between stages until
arriving at the final stage of acceptance. It is coming to rest at the
acceptance level that one can understand and experience the act
of surrender. It is here one can sense a lifting of the obsession, no
longer needing to struggle with abstinence, but rather finding a
comfort and rhythm to recovery. Ambivalence about recovery

130. 118
dissolves and intervals of serenity and acceptance of “life on life’s
terms” begin to increase.
Over the years Tiebout believed this “conversion experience” is
exemplified by:
• The switch from negative to positive behavior by the
act of surrender
• The cessation of defiance and grandiosity: attaining a sense
of humility
• Surrender being synonymous with a marked change
in behavior[s].
• Surrender, when maintained, exerts a positive influence on all
spheres of ones’ life: physical, emotional, and spiritual.
In effect, getting to this stage in recovery can be viewed as the
precise moment when the tendency toward defiance and ego
driven self-control cease to function effectively. With this, the
individual is totally open to accepting reality. Honesty, open-
mindedness, and willingness replace the negativity and
grandiosity, often the least attractive personality traits common to
most addicts. As the good doctor reminds us, “the act of surrender
is an occasion wherein the individual no longer fights life, but
accepts it.” My suspicion is this process coincides with the
progression of spiritual growth. In effect, there is an acceptance of

131. 119
humility and a healthy balance between appropriate self-reliance
and reliance on something other than one’s self [ego].
Marty Lerner, Ph.D.
The Transition Home
The most important piece of the treatment experience is the ability
to transfer your experiences to the real world, namely continuing
in recovery after returning home. No one does this perfectly. The
whole idea of recovery is not for it to become your life, but to
enable you to get a life. That being said, your success will greatly
depend on having practiced daily living skills during your time in
treatment. The actual experiences of doing the grocery shopping
and food preparation, attending OA, ABA, and other relevant
groups, following an exercise plan, finding a balance with work,
rest and play, and all the other behaviors associated with
maintaining an eating disorder free life, will enhance your chances
for continued recovery at home. To the degree your last day in a
treatment program is a close fit to your next day home, is the
extent to which you have benefited from your hard work. Once
more, intellectual knowledge of recovery has little to do with the
understanding coming from the doing part.
Continuing your recovery still involves a level of commitment after
you leave the treatment setting. Rather than propose a long
dissertation as to what needs doing for “life after treatment,”

132. 121
suffice it to say that long-term recovery is a function of practicing
the S.E.R.F. formula on a consistent basis, as well as, working all
the steps of the 12-Step group you choose to follow. Doing this will
virtually insulate you from relapse if done on a regular basis. Like
taking care of ones’ self with any chronic illness, it will require
some effort and discipline day to day. However, as said before, it
is intended to allow you to “get a life” and not become your life.
Just put the [SERF] eggs in the bowl before the rest of the stuff that
seems to demand “all” your time and attention.
Summary
Before moving on, let’s take a moment and reflect on what’sbeen
discussed so far. Despite being a little too close to the forest
myself, I’m hopeful by now the reader has an appreciation ofboth
the nature of the problem and the suggestions for long-term
recovery.
We defined the problem in terms of the physical, emotional
[psychological] and spiritual consequences inherent with an eating
disorder. We looked at what all eating disorders have in common
rather than looking at them as separate entities. We saw the
similarities between an eating disorder and other forms of
dependencies and addictions. Looking forward, we began to better
understand the dynamics of both the disease and treatment.

133. 120
I’ve presented the case for looking at an eating disorder, regardless
of subtype, through the addictions prism. Taking an open and
honest look at the traits common to dependency and addiction in
the earlier part of the book, I’ve left it to you to make your own
diagnosis. Going from the problem to the solution, we’ve covered
a few elements common to the treatment of most eating
disorders. We’ve proposed an approach that depends less on
analysis and more on action. Once more a discussion of therapy
has looked at the benefits of purposeful action and the limits of
most talk therapies as it relates to eating disorders. To that end,
there’s been a set of specific “laws of behavior” given to the reader
to test out for themselves. The primary elements of Constructive
Living were considered as parallel to the suggestions common to
all 12-step recovery. They stand as universal principles that appear
simple to understand, but are a challenge to accomplish with
consistency.
Some of what was written outlines a collection of experiencesand
opinions evolving from several years in the field. Being on the
treating end of these disorders and listening to the stories of my
patients, has been enlightening to say the least. More importantly
perhaps, wearing the hat of having had a personal relationship
with addiction and recovery has been even more enlightening.

134. 123
A significant amount of what’s been presented here also comes
from the scientific literature uncovering some of the mysteries of
the brain. We know more today how addictions and eating
disorders function and what differences exist between people with
and without these disorders. Still, much of what we know today
springs from the courage of so many people overcoming their
“addiction” and sharing their experiences with others, others
looking for what they have found, namelyrecovery.

135. 122
Chapter 5
Continuing Care - After Treatment
"The greatest thing in this world is not so much where westand,
as in what direction we are moving."
- Unknown
"Nobody ever found recovery as a result of
intellectual awakening."
- Anonymous
“Religion is for folks that want to avoid going to Hell.
Spirituality is for those of us who’ve already been there”
- Unknown

136. 123
12 Step Groups and OngoingRecovery
Given the assumption most eating disorders are inherently
chronic, lifelong illnesses characterized by either short or long-
term periods of remission, we need to consider what affords the
best chance for sustaining recovery. A statement from the
American Society of Addiction Medicine published in 2012 goes on
to say, "Like other chronic diseases, addiction (I will include eating
disorders here) involves cycles of relapse and remission. Without
treatment or engagement in recovery activities, addiction is
progressive and can result in disability or prematuredeath."
To be clear, most physicians, health professionals and the public at
large would have little problem accepting an insulin dependent
(Type 1) diabetic's need to follow a daily routine to fend off the
consequences of their disease. Likewise, looking at any number of
chronic diseases, there seems to be an element of ongoing
treatment or self-care that is necessary to hold the disease in check
or prevent further deterioration. Unfortunately, when it comes to
the disease of addiction, accepting this reality is illusive. In fact,
the "symptom" of denial or rationalization is so prominent as to
convince someone that "coasting on yesterday's treatment" is
sufficient to ward off relapse. Not long after someone is deluded
into believing they are "cured" or no longer need to rely on
anything other than self-will to sustain recovery. More oftenthan
not, experience reveals nothing could be further from the truth.

137. 125
Usually the only unknown is when, and not if, relapse will follow.
Although not the only format for ongoing support and recovery,
the basic tenets of 12-Step Programs appear to offer the greatest
opportunity for those suffering with an addictive illness for long-
term, if not lifelong recovery. Although some may benefit from the
professional resources available outside of these groups, all 12-
Step groups provide a "prescription," if you will, for eliminating the
self-destructive substances or behaviors hijacking the addict's life.
Beyond the "1st
Step" of these programs, the suggestions outlined
in the remaining 11 steps are identical. The differences amongthe
programs rest within those attending specific fellowships such as
Overeaters Anonymous, Alcoholics Anonymous, Narcotics
Anonymous, Anorexics and Bulimics Anonymous, Gamblers
Anonymous, and so forth. It might be worth noting, many people
who suffer with an eating disorder also suffer with related
addictions, such as, alcohol dependency, drug addiction,
compulsive gambling, etc. As such, attendance at different
fellowships is not so unusual today, as we begin to recognize
addiction as a disease with similar characteristics having to do with
the nature of the person rather than the properties of a specific
substance or behavior.
Specific to eating disorders, Overeaters Anonymous and Anorexics
and Bulimics Anonymous are among the most attended support
groups offering fellowship and on-going support for those with an

138. 126
eating disorder. Each of these programs is self-supporting and
does not charge dues or a fee for membership or attendance at
meetings. Each has literature available to outline the experiences,
suggestions and "steps" that are the foundation of their respective
programs. Each also lists resources and websites that link people
to online meetings, schedules and locations of local meetings,and
a variety of other materials related to eating disorder recovery.
There are several slogans, sayings and "catch phrases" that have
circulated within 12-Step recovery programs. Those encouraging
people to practice H.O.W. – Honesty, Open Mindedness and
Willingness, and to avoid the tendency to prejudge due to –
"contempt prior to investigation" – are essential to those new to a
12-Step Fellowship.
In the end, the purpose of any 12-Step fellowship and program is
not to replace professional treatment when needed, but serve as
a consistent long-term support network. Most members of these
groups find regular attendance at meetings in conjunction with
"working the steps and helping others" as indispensable to their
recovery. If asked, they would likely explain their consistent
participation is not a "sentence," but rather a "reprieve" from the
misery of an eating disorder, albeit "one day at a time."

139. 127
Open Letter for Revised Edition of Basic OAText
Revised and published in the forward OA 3rd edition, 2014
In August of 2010 Overeaters Anonymous celebrated its Golden
Anniversary at its world convention in Los Angeles. As someone
who has treated compulsive overeaters for more than three
decades, I was privileged to be an invited guest to join in the
celebration. As a point of reference my professional relationship
with OA dates back to my earlier years in practice, as I began to
refer many of my patients to the local OA groups in my area. Doing
so left me indebted to the courageous members of this fellowship
who taught me so much more about this disease than I could have
ever imagined. Since that time, Overeaters Anonymous has been
of virtually indispensable support for those who have come to our
facility seeking treatment. Here's a little background to shed light
on some of my experiences through the years.
Before delving into my history with OA, I’d like to put forth a brief
editorial comment at the outset. That is, I have long believed
Overeaters Anonymous not only serves as a program of ongoing
recovery for those suffering with compulsive overeating, but also
for those struggling with similar eating disorders. More specifically,
I have continued to witness the success of countless people
working the same 12-Steps, adopted from Alcoholics Anonymous,
in OA. Many of my patients, past and present, suffering with
bulimia, binge eating disorder, and related eating disorders have

140. 128
found refuge and recovery at the meetings and among the
fellowship that OA offers. Truth be told, I believe OA holds a place
for anyone wishing to refrain from a compulsive or addictive
relationship with food.
I finished my training as a clinical psychologist in 1979, passed my
boards, and began a practice specializing in the treatment of eating
disorders. As part of my graduate work, I had been engaged with
various research projects examining the regulation of eating and
body weight. You could say I became an expert on what made
laboratory rats and mice overeat and become overweight. You’d
be surprised to learn humans and rodents are quite similar when
it comes to being predisposed to abnormal eating. Anyway, over
the course of the next several years I graduated to treatingpeople
with varying types of eating disorders, most notably compulsive
overeating, bulimia, and what is now termed binge eating disorder.
What I discovered, over time, was simply that weight was but the
symptom, and the disease was really an addictive relationship with
food and/or dieting. I say this because I began to see people at the
university’s clinic who were not overweight, yet clearly ate
compulsively. Most of these compensated for their overeating by
either “making themselves sick” and getting rid of the food, over
exercising, or alternating between periods of copious overeating
followed by restricting, aka dieting. Of course, the majority of folks
coming to our program suffered with varying degrees of obesity,
the symptom most identify with compulsive overeating. Despite

141. 129
this, I soon concluded the more appropriate measure of the
problem lies with the physical, emotional, and spiritual
consequences and not the number on a bathroom scale. In effect,
compulsive overeaters had more in common with their alcoholic
and drug addicted brethren than most realized. There was more to
this than a “weight problem.” In fact, today we see any number of
AA and NA members who are also compulsive overeaters, and
attend OA meetings as part of their ongoing recovery programs.
Not so different than the misguided beliefs about alcoholism in
years past. The professional community is currently divided as to
how to view, let alone treat, compulsive overeating and related
eating disorders*. If we distill the basic essence of the division, it
would come down to those who view the compulsive eater as
suffering with a psychiatric illness, coupled with a lack of discipline,
and those who view it as an addictive disease. Historically,
however, there has always been a small group of researchers,
physicians, and healthcare professionals who have held steadfast
to the addiction thesis. I’m pleased to report this minority group of
professionals is multiplying and gaining momentum. Fact is, recent
advances with brain mapping technology, such as MRI imaging,
have clearly identified specific chemical responses in the brain that
differentiate the compulsive overeater from his “non-addict”
peers. The evidence has taken speculation and theory to the level
of scientific fact. Personally, this has only served to validate those

142. 131
of us supporting OA through the years – namely compulsive
overeating deserves to be recognized the same way we’ve come
to understand and treat alcoholism and drug addiction.
It’s been my experience that active participation in a 12-Step
program such as OA, is indispensable to the ongoing success of
anyone wishing to recover from compulsive overeating or a similar
eating disorder. Although not intended as a substitute for
professional treatment when called for, OA affords the best
opportunity to gain and keep a foothold in recovery. For purposes
of making this point, I’d like to add a quote from the American
Society of Addiction Medicine as it defines the disease of addiction.
One can substitute the phrase compulsive overeating to clearly see
that the proverbial shoe fits.
“Addiction is a primary, chronic disease of brain reward,
motivation, memory and related circuitry. Dysfunction in these
circuits leads to characteristic biological, psychological, social and
spiritual manifestations. This is reflected in the individual pursuing
reward and/or relief by substance use and other behaviors. The
addiction is characterized by impairment in behavioral control,
craving, inability to consistently abstain, and diminished
recognition of significant problems with one’s behaviors and
interpersonal relationships. Like other chronic diseases, addiction
involves cycles of relapse and remission. Without treatment or
engagement in recovery activities, addiction is progressive and can

143. 130
result in disability or premature death.” -American Society of
Addiction Medicine, 2012
Just about anyone who has attended a support group such as OA
for any reasonable period of time will likely hear “their story” told
by another member. The effect of one person’s experiences shared
with a fellow having the same experiences is, to quote a related
program, “unparalleled.” Once the initial layer of the onion is
peeled away, namely the “but I’m different than these people,”
then the stage is set for identification rather than comparison. The
question then becomes, “so what do I have in common with all
these people?” “Maybe I’m not alone or so different.” From that
point forward, the focus begins to center more on the solution –
“what do I need to do to recover?” The “magic” of OA seems to
then become clear - a combination of people having a common
purpose and seeing others working a set of suggested steps,
lending testimony to the promise of recovery.
It is my sincere hope the fellowship will continue to grow and its
members serve as a beacon of light to show the way to thosewho
have yet to find OA. It’s a spiritual axiom, that a group of people
with a common history and purpose can do as a group what could
not otherwise be achieved by the individual. In that sense, OA
offers what no professional or single person can match – hope by
example. -Marty Lerner, Ph.D. 2014

144. 132
S.M.A.R.T - An Alternative or Add-On to 12 Step
Organizations?
Reprint of a “Self Growth” article written [M. Lerner, Ph.D. 2014]
In the world of addiction treatment there are several choices one
has in the way of utilizing and attending a community based
support group. Should one look more closely at what is offered to
those with an eating disorder the choices are somewhat more
limited, but none-the-less do exist. This article takes a look at two
diverse, yet complimentary approaches, 12 Step oriented
programs and the SMART Recovery program.
A detailed description of both may be beyond the scope of this
article. However, suffice it to say both “philosophies” or “beliefs”
have inherent similarities, as well as, differences. To that end, I
hope to distinguish what each brings to the table that is unique and
what they share in common.
SMART Recovery Basics
Let’s begin with what SMART (SR) stands for, namely Self-
Management and Recovery Training. In a nutshell, SR offers a 4-
Point Program [not to be confused as “steps”] that amount to 1-
Building and Maintaining Motivation, 2- Coping with Urges, 3-
Managing Thoughts, Feelings, and Behaviors, and 4- Living a
Balanced Life. SR can serve as a stand-alone approach or

145. 133
compliment another program such as a 12-step group or
professional treatment. SR does not necessarily adhere to the
premise that one need attend meetings as part of a lifelong
process, as there is a beginning, middle and end to treatment for
an addiction. Hence once an “addict” you are not always an addict.
Another, what I believe to be very important distinction, SR is
intended to be open to support any addiction and does not hold
separate groups for compulsive overeaters, alcoholics, drug
addicts, compulsive gamblers, and affected family members.
Virtually anyone with an addictive or compulsive behavior[s] with
a desire for abstinence from these, may benefit from attendance
and are welcomed.
Having the benefit of experiencing both a 12-Step Program for
many years and, more recently becoming a trained facilitator for a
SMART Recovery group, I would say SR represents a more updated
approach to addictive problems. Although there are no bona fide
studies to support the efficacy of one support group over another,
there is ample research to support the effectiveness of the“tools”
and techniques taught in the groups. These include motivational
interviewing techniques, cognitive behavioral approaches to
confronting urges and destructive behaviors, and developing
alternate healthy lifestyles to replace addictive and compulsive
behaviors. SR encourages participants to take an active role in the
group process, and unlike the format of a 12-Step meeting, talking

146. 134
between group members is encouraged. In effect, each participant
serves as a therapeutic agent in the meeting. Last, but certainly not
least, much of the literature offered by SR incorporates a “how to”
compilation of the tools and techniques discussed at the meetings.
Rather than “steps” to be completed, the SR Handbook, as an
example, provides an ample supply of worksheets and structured
assignments that correlate with the four point program outlined
from the beginning – motivation, coping with urges, managing
emotions, thoughts, behaviors, and lifestyle change. Although not
dissimilar from the 12-step notion of “into action”, SR is a program
of “doing is believing” rather than simply an intellectual exercise.
In passing, it’s worth noting SR holds no requisite that cultivating a
spiritual belief system or reliance on a “Higher Power” is
synonymous with ongoing recovery. SR does not discourage or
encourage individuals from bringing their religious or spiritual
beliefs into their “personal” program of recovery. SR is quick to
point out it is not a spiritual based program and as such, steers
clear of incorporating such principles in their approach to
abstinence.
Comparison with 12-Step Programs
First, I would begin by stating both programs are careful not to
claim superiority with the belief “one size fits all” with respect to
addiction recovery. As such, the “bashing” of one program versus

147. 135
the other is discouraged and both programs promote a philosophy
of open mindedness and seeing what works best for anyone
seeking abstinence* from their addictive substance or behavior[s].
*Both programs support abstinence, but SMART does not require
abstinence from "everything," only those substances or activities
that are selected for abstinence by the participant.
While on the topic of similarities, it’s also important to note both
programs encourage the use of medical and relevant professionals
when appropriate, as an integral part the recovery process.
Inherent with that policy is the notion SMART Recovery and 12-
Step programs are there to serve as a support network and not a
substitute for medically necessary treatment when called for.
Indeed, one may argue there is a practical difference between a
support group and a treatment program. For a substance
dependent person medically supervised detoxification may be
indicated as a life-saving procedure. Likewise, for someone in the
grip of an eating disorder, medical stabilization and a structured
setting may be necessary to gain a foothold in the beginningstage
of the recovery journey. Yet for others, the frequently associated
mental health issues, such as depression, may require the use ofa
suitable medication, and so on. Although I could go on with a list
of other relevant common denominators, I would suggest
someone approach each with an open mind and experience both
groups a fair number of times, to be in a position to choose which,

148. 136
if not both, offer the best opportunity for continued abstinence.
Indeed, some people will choose one program over the other while
still others will see each group as offering something unique and
worthwhile – opting to attend both on an on-going basis.
To someone reading this with no prior experience with a 12-step
program, I would suggest it is, at least for me, difficult to put an
aggregate of experiences into words to adequately describe them.
What I would say, unlike SR meetings, 12-Step groups are intended
primarily for specific addictions and are not one “fellowship” but
many. In other words, alcoholics would attend an AA meeting
[Alcoholics Anonymous], Overeaters go to OA, Anorexics and
Bulimics [ABA], Compulsive Gamblers [GA], and so forth.Although
not a religious program, there is a strong current of encouraging
someone to work toward their own version of “a power greater
than themselves” or a sense of spirituality, without defining what
that should be for the individual. In this sense, the program is not
religious and purposely leaves the concept of a higher power
strictly up to the individual. To be sure, there are members who
have succeeded in these fellowships who are agnostic or atheists,
and there are no “musts” in the program as outlined in their
literature. The [suggested] steps represent a series of actions or a
progressive formula participants are encouraged to complete over
time – with the inherent belief that doing so will not only result in
continued abstinence, but also lead to a more productive and

149. 137
satisfactory lifestyle, usually referred to as recovery. Although
much can be said pro or con for 12-step programs, the proliferation
of groups and meetings is enormous, with hundreds of meetings
taking place on a weekly basis in just about every major city here
in the U.S. and throughout the world. Membership in AA alone is
in the several millions and the off spring programs attended by
hundreds of thousands if not millions of others. Perhaps one of the
greatest strengths of 12 step programs is the frequency of
meetings and the fellowship opportunities they provide for people
to find support and some hope with their struggle to free
themselves from the tyranny of their addiction.
As mentioned, I would encourage someone looking to initiate the
recovery process or to add to an existing repertoire of recovery
support, to attend several of these meetings and then decide
which, if not both, prove helpful. To learn more about these
meetings and groups you can go to http://www.smartrecovery.org
as well as, a particular 12-step fellowship site such as
http://www.AA.Org or http://www.aba12steps.org/,etc.
Marty Lerner, PhD
CEO, Milestones in Recovery

150. 138
Continuing Care Resources
Just as a point of reference, there are a number of on-
going methods to connect with Milestones’ alumni, as well as
others with similar histories, to help keep your recovery.
There are opportunities to attend twice monthly and monthly
aftercare meetings. These are available in Philadelphia, New
York, and Richmond, VA, as well as, at our offices in South
Florida. An up-to-date list of topics and dates is available onour
website: www.milestonesprogram.org under the News section.
These groups are open to anyone wishing to participate.
There is also an opportunity to access our support groups via
toll-free teleconference sessions*. Beyond these options, there
is an individualized continuing care plan integrated into the
program here at Milestones, and presented to each participant
prior to discharge. This is the case for most other ED programs
as well. For those not having completed treatment at
Milestones, we offer group and message board forums on our
social networking groups at Facebook and Yahoo Groups,which
can be accessed via our website’s home page.
Last, but certainly not least, are groups such as OA (Overeaters
Anonymous), ABA (Anorexics and Bulimics Anonymous), and
a variety of other relevant 12-Step and non-12-Step support

151. 139
groups.These are available throughout the U.S. and
internationally. Both of these organizations list meetings that
can be attended in person and online via theweb.
* To participate in the eating disorders support group via
teleconference calls, contact us via our website,
www.milestonesprogram.org or call our toll free line at 800-
347- 2364 for a schedule of meeting times and the toll free
conference number.

152. 141
Chapter 6
Additional Information

153. 140
Understanding Insurance and the Cost ofTreatment
A clear and concise understanding of your insurance benefits and
what will or won’t be covered for an eating disorder [or a related
diagnosis] can be both confusing and overwhelming. As an
example, your insurance may list mental health as a covered
benefit [eating disorders fall within that category], but require you
to be “pre-certified” for a specific treatment [level of care]. In
doing so, the insurance company typically will utilize a set of
criteria to determine if the severity of your eating disorder meets
their criteria for “medical necessity”. As such, it’s possible you may
have the benefit, but are denied access to the program or level of
care you are looking for.
Typically, when someone considers coming to a residential, day
treatment, or intensive outpatient program such as ours, they
participate in a clinical assessment to determine their treatment
needs. Although most insurance benefits include mental health
benefits, including a residential program, a few do not.
However, assuming you do have benefits that include the
continuum of care [residential, partial hospital, and intensive
outpatient options], the provider or program will be better able to
estimate what will or will not be approved based on the findings of

154. 142
your clinical interview [assessment]. Often the assessment can be
conducted via a structured phone interview.
As if the above isn’t complicated and confusing enough, there is
also the matter of what your particular insurance policy requires
as a “deductible” and what your “co-pay” would be for particular
services. Usually, these will be a function of whether you are
requesting services from a “network” or “out of network”
provider. Out of network providers [facilities and providers] usually
involve a somewhat greater “out of pocket” expense on your part.
That said, the good news is that after you reach [spend] a specified
amount of your own money, your insurance will typically cover
100% of the remaining costs provided you are “certified” for the
treatment you’re requesting.
By way of example, someone coming to a program or provider
contracted with XYZ insurance, may have a $250 deductible and no
co-pay for residential treatment for an eating disorder. In this
instance, the maximum out of pocket expense or financial
responsibility for that person is limited to $250 – assuming
the insurance company’s medical criteria for that level of care is
met. Likewise, someone who has a different plan may have no
deductible and no co-pay, and hence have no out of pocket
expense. Lastly, someone who is using an out of network benefit
will likely still be covered after their deductible is met,and, in some
instances, have a small daily co-pay during theirstay.

155. 143
Given all the above variables and possibilities, it comes down to
finding someone who can verify your benefits and be able to give
you a clear understanding of what to expect. In doing so, it is
important to realize some of the answers to your concerns can only
be estimated and predicted on past experiences with your
insurance company. This is because your insurance company will
not usually commit, in advance, to a specific length of stay at a
given setting or level of care. As such, you will want to know what
contingency plan exists should your insurance company [or your
managed care company] decide you no longer need treatment at
that level of care or program.
In effect, you may want to discuss your “worst case scenario”
before you commit to a treatment program, as well as, what the
most likely scenario will be. Unfortunately, there is typically some
element of uncertainty when dealing with insurance coverageand
treatment. Your job is to minimize this uncertainty, so you can
focus on the task of recovery. Here is where the experience and
integrity of the person reviewing your insurance is so important.
This process begins with a call to the provider or facility admissions
director. Knowing the proper questions to ask is important.

156. 144
Here are a few questions to ask…
• Are you in-network with my insurance company?
If not, will you accept my out of network benefit?
• What is my out of network benefit and deductible?
• What is my daily co-pay, if any, at your program?
• What is the likely maximum out of pocket expense at
your facility for the level of care I need per day?
[e.g. residential, day treatment, or intensive outpatient]
• What can I expect my out of pocket expense will befor
the recommended length of stay
• What is the average length of stay at your program?
• Will I receive a bill for treatment after I leave?
• Will I know prior to admission what my insurance will and
will not pay for?
• Will you let me know beforehand, if there is any denial of
authorization for treatment, that I will be responsible
for later?

157. 145
Clean Eating (Abstinent) Suggested Recipes
In order to guide the reader toward the spirit of clean eating and a
healthy food plan, I’ve taken the liberty of assembling a few recipes
for consideration.
Special thanks to our alumni, our own Milestones dietitian, Nikki
Glantz, R.D., and the folks at the Miami Dade group of O.A. for
giving us permission to include some of their “creations.”

158. 146
Breakfast Pancakes, Oatmeal, CottageCheese
(2 servings)
1 ½ cups rolled oats
3 tbsp. oat bran
1/3 cups cottage cheese
3 egg whites
1 tsp. vanilla [alcohol free]
Mix in blender until smooth, cook “batter” a la pancake in pan
with Pam

159. 147
Cold Cereal extraordinary
(1 serving)
1 oz. dry cereal [corn or rice flakes, puffs, etc.]
1 cup yogurt [sugar free]
1 cup peaches [frozen]
sugar substitute [optional]
1 tsp. vanilla [optional and non-alcohol]
Mix all ingredients and place in freezer for 5 minutes…

160. 148
Oat Bran, Apple Walnut Porridge
(1 serving)
¼ cup oat bran
½ cup applesauce
2 oz. walnut pieces
1 cup water
1 packet artificial sweetener
ground cinnamon to taste
Bring water to a slow simmer. Add oat bran and cook[stirring]
until thickened - [about 3 minutes]

161. 149
“The Doctor’s Opinion” Pancake
(1 serving)
½ cup quick cook [instant] oatmeal
2 eggs / or equivalent egg beaters
2 tbsp. low fat yogurt
1 tbsp. low fat sour cream [optional]
2 tbsp. sugar free maple syrup [optional]
Mix until a batter [using a blender is best], spray Teflon 6” pan
with non- calorie vegetable spray [Pam], and flip over andfinish
as a pancake.

162. 151
Oat Bran Muffins
(2 servings)
2 eggs
½ cup ricotta cheese [low fat]
1 cup oat bran
2 cups blueberries
1 tsp. agave nectar [or sugar substitutepacket]
½ tsp. baking powder
1 tsp. vanilla [alcohol free]
cooking spray
Mix all ingredients and pour into muffin tins. Bake at 350degrees
for 20 minutes.
Let cool, remove from muffin tins / pan wrap tightly in plastic
wrap and store in fridge or freezer. To reheat, microwave in a
slightly damp paper towel.

163. 150
Chicken and White Bean Salad
(2 servings)
6 oz. chicken, chopped
4 oz. cheese, feta crumbled
1 can cannellini beans, canned, drained
1 cup zucchini, diced
1 cup celery, diced
2 cups lettuce, romaine, raddichio, endive
4 tbsp. olive oil
2 tbsp. vinegar, or lemon juice
6 tbsp. orange juice
1 tsp. mustard, prepared brown
1 clove garlic salt and black pepper
Dressing: Peel the garlic clove and smash with side of a chef’s
knife. Use a fork to mash the garlic with ¼ tsp salt in a small bowl,
forming a course paste. Whisk in oil. Add the orange juice,
vinegar, Dijon Mustard and pepper to taste. Whisk until well
blended. Set aside.
Notes: The classic vinaigrette recipe is 3 parts oil to 1 part
vinegar. You can decrease oil ratio if you substitute less tartrice
vinegar, lemon juice, or a combination of vinegar and orangeor
grapefruit juice.
You can use any canned white beans such as garbanzo,
[cannelloni beans are also known as navy beans].

164. 152
Chicken Avocado Layered Salad
(2 servings)
8 oz chicken, cooked
2 cups lettuce, shredded
½ cups sliced radishes
1 stalk celery
1 medium scallions, sliced
8 tbsp. avocados
½ tsp. Worcestershire sauce
3 tsp. vinegar, rice wine, or any kind vinegar
¼ tsp. mustard, dry
4 tbsp. water
1 cup rice, brown, cooked
Salt and pepper to taste
1. In a large bowl, layer ingredients in the following order:
half the lettuce then radishes, then chicken, then celery,
then remaining lettuce, and the scallion.
2. Dressing: Mash avocado in a small bowl. Blend in dry
mustard. Add vinegar, Worcester sauce, and water. Mix
until creamy

165. 153
Crab and Avocado Salad
(2 servings)
8 oz crab meat
1 medium tomato, plum, seeded and chopped
½ cup celery, chopped fine
½ small red onion, minced
1 medium avocado, peeled and cubed
2 cups lettuce, boston
2 tsp. lime juice
1 cup amaranth. cooked
Salt and pepper to taste
1. In a medium glass or ceramic bowl, combine the onion,
lime juice, tomato, salt and pepper. Add crab and toss
gently with avocado, lettuce, and celery
2. Serve over cooked amaranth or sprinkled with popped
amaranth.

166. 154
Egg and Goat Cheese Frittata
(4 servings)
5 eggs
2 tbsp. milk
1 cup tomatoes
3 oz. cheese, goat crumbled
2 cups frozen broccoli chopped [thawed]
2 cups brown rice, cooked
Salt and pepper to taste
1. Mix eggs and milk in a large bowl. Add crumbled goat
cheese and chopped veggies and cooked rice. Season with
salt and pepper.
2. Spray muffin tin with cooking spray [Pam]. Spoon egg
mixture into muffin tins.
3. Bake at 350 degrees-15 min or until set and lightly
browned
4. Refrigerate until ready to serve-then heat in microwave
30 sec.

167. 153

168. 156
MILESTONES IN RECOVERY located in Cooper City, Florida
offers both residential and outpatient treatment for eating
disorders. The program at Milestones offers a blended
approach to treatment – addressing both the addictive and
emotional aspects of an eating disorder. Unlike a traditional
inpatient or hospital environment, Milestones affords an
opportunity to gain a foothold in recovery in a less
restrictive setting, while still providing necessary support
and structure. This involves supervised grocery shopping,
learning about and preparing meals for oneself, and
engaging in both therapeutic and leisure activities outside
the confines of a hospital setting. In effect, we offer an
opportunity to put into practice, that which is necessary to
free someone from their eating disorder.
Do you or someone you love
suffer from an eating disorder?
Do you have questions?
Unsure if treatment is right for you?
Call us toll free 800 347.2364
MARTY LERNER, PhD is Executive Director of Milestones in Recovery. A graduate of
Nova Southeastern University, Dr. Lerner is a licensed and board certified clinical
psychologist who has appeared on numerous national television and radio
programs, including: The NPR Report, 20/20, Discovery Health and ABC’s Nightline,
as well as, authored several publications related to eating disorders in professional
literature, national magazines and newspapers including USA Today, the Wall Street
Journal, New York Times, Miami Herald, Orlando and Hollywood Sun Sentinels. An
active member of the professional community here in South Florida, Dr. Lerner
makes his home in Davie with his wife Michele and daughters Janelle, Danielle and
their dog, Reggie.
2525 Embassy Drive, Suite 10
Cooper City, FL 33026
800 347-2364
http://www.milestonesprogram.org

169. Milestones Nutritional Guidelines
Abstinent Food Plan
Revised 1/15
Disclaimer: The information and suggestions in this manual are based on the author’s training and experiences in helping many people in
recovery. Please consult your family practice physician and any other medical professionals who understand your individual health situation before
beginning this or any other plan of eating. This material is not a substitute for any medication or treatment prescribed by your doctors. Food,
medications, allergies, and intolerances are individual and can interact in unpredictable ways. This publication is intended to be helpful and
informative. It is not a substitute for professional medical care or personalized professional services. Please use this manual only as a basis for your
work with your chosen medicalprofessionals.

170. 2
What is a Food Plan?
What is a food plan? Why would I need one? Why would I ever want one?
A food plan is a description of the foods you will eat in a specific and planned way: it describes what you will eat, when
you will eat, how much of each food you will eat, and when you will stop eating. The foods that you avoid eating are
not included on your food plan.
This food plan is designed for people in recovery from “food addiction”, or “compulsive eating”, using the addictive
model and a Twelve Step recovery program. It is designed to be used as part of a process with a registered dietitian.
Your recovery process is best shared with others who can help you, such as a dietitian/nutritionist, sponsor, support
people, and other health care professionals.
To diminish abusive, compulsive behaviors, recovery food plans have thesecharacteristics:
• Remove all foods, which set off or perpetuate inappropriate or self-destructive foodbehaviors
• Meet the nutrient requirements of the body
• Minimize food cravings
• Provide enough food to feel satiated - not ravenous or overstuffed throughout theday
• Help manage any medical problems
• Be flexible enough to allow participation in normal activities
• Provide adequate time and energy for other lifestyleactivities
• Allow space for spiritual pursuits
As you and your nutritionist begin creating an individualized food plan, please remember that no decision is
permanent. A food plan must be individualized to your specific situation. Together, adjust your food plan until you find
a pattern of eating that works well for you. If your food plan program is stable and comfortable, use the information in
this book to broaden your choices.
Please note: If you have any medical condition (diabetes, hypertension, pregnancy, etc.) or if you have
anorexia or bulimia, it is not safe for you to try to follow this food plan by yourself. Be certain to get
adequate appropriate professional help!
Please do not try to create a food plan on your own. By picking up this booklet, you know that solving this problem by
yourself has not worked. Choose one person, like your registered dietitian or other health care professional, to help
you make decisions about the content and direction of your food plan. Then commit to follow the food plan for a
specified period of time, or until you agree with that one chosen person to changeit.
The primary purpose of the food plan is to provide a structure for abstinent eating. Abstinence means freedom from
self-abuse and obsession with food. It means you no longer use food to manage feelings; it means you no longer starve,
restrict, overeat, binge, purge, or do other harmful things to yourself with food. It means you have enough nutrient-
rich foods to maintain your body at a healthy normal weight. It means you have the flexibility to live a joyful, useful life
without struggling around food. The food plan begins the process of abstinence by removing all binge and trigger foods
and by providing balanced, appropriately sized meals and snacks. Trigger foods are foods that set off your cravings or
your desire to use food inappropriately. Trigger foods vary from individual to individual. Some foods may trigger you on
a physical level. Others may need to be removed because of what they symbolize - what they have meant to you in the
past - as a comfort food or as a way to manage feelings orsituations.
Binge foods are those you choose first and use the most often in the process of eating abusively. Any food you used to
stuff yourself, to avoid painful life events, to medicate feelings, or to punish or to nurture yourself may need to be
removed temporarily or permanently.

171. 3
Foods that are similar to your binge foods - that look, smell, or tastes like them - or that are made from the same
physical ingredients - also need to be removed. Dietetic “
desserts” may set off your desire to overeat because of their
similarity to foods you have eaten abusively in the past. Remove any and all foods that consistently set off your need to
eat inappropriately.
Foods are divided into categories based on their nutrient content. What follows are lists of the foods and food
categories with comments and suggestions for each.
Using these food lists, a food plan will be created by your dietitian listing the servings of each food at each time of day.
You may choose any food within a category; do not replace foods in one category with those from another. Do not
combine meals or snacks, move foods from one meal to another, or skip foods or meals. If the food plan is
uncomfortable, discuss it with your dietitian; please do not change your food plan byyourself.
The food lists and your meal plan will specify portion sizes and amounts. Since balancing protein and fat with
carbohydrate is very important for diminishing cravings, as well as weight gain or loss and nutrient intake, establishing
appropriate portion sizes is essential.
To make sure you are getting the correct amounts of the foods specified, we recommend weighing the portions. Most
compulsive eaters find that after a period of inappropriate eating, the ability to accurately estimate portion sizes is
diminished or distorted. Portion sizes are often underestimated for some foods and overestimated for others.
Weighing (a measurement of weight) is done with a food scale and in ounces, and measuring (a measurement of
volume) is done with a measuring cup or cups, and measuring spoons. When weighing foods please be sure foods are
in the cooked form. One cup of liquid weighs eight ounces, but one cup of solid food may weigh more or less than eight
ounces. Adding liquid by steaming, boiling, etc increases weight and may increase or decrease volume. Reducing liquid
by baking, broiling, or roasting decreases weight and may or may not change thevolume.
The food plan will specify weights of foods to be used.

172. 4
Sugars
Definition
A carbohydrate is a food nutrient that provides a major source of energy. The main form of carbohydrate used to
generate energy is glucose.
There are 3 types of carbohydrates:
• Sugars
Y Monosaccharides (glucose and fructose)
Y Disaccharides (sucrose and lactose)
• occur naturally in fruit, some vegetables, milk, andsweets
• Starch - foods with many sugar molecules strung together
Y Digestion and absorption depends on the structure of the starch, how it is packaged in the plant source, and
how the food is processed and cooked.
• cereals, grains, and legumes
• Fiber - starches that are not digested
The sugars that are absorbed after digestion are responsible for increasing blood glucose concentration. This can be
affected by the other foods eaten at the same time, the speed with which your stomach empties, and the way your
intestines and other body processes work.
Recommendations
In a compulsive eater, bulimic, or anorexic, large amounts of high-sugar foods are believed to cause the mental and
physical responses that lead to inappropriate eatingbehavior.
Because sugar occurs naturally in many healthy foods, it is not advisable to remove all sugars from your food plan.
However, it is necessary to reduce your intake of sugars to the point where your physical cravings are no longer
triggered. This point varies from person to person. To begin, this plan removes nearly all added sugars and all high-
sugar foods, sweets, and desserts.
Sugars are added to all sorts of foods in processing, and some foods contain primarily sugar and fat. Remove all foods
with unnecessarily added sugars. Balance carbohydrate sources with protein and fat. Read labels; in order to reduce
food cravings, sugar needs to be after the first four ingredients on the ingredient list. Some people may need to be
even more rigorous. If your cravings continue, remove all of the foods with any sugar in the ingredient list. Discuss this
matter with your dietitian and do whatever works to best manage your triggers andcravings.
If there are three or more sugars in a food, even below the fifth ingredient, check with your dietitian before using it.
Beware of “sugar-free”
By definition a “sugar-free” product does not contain carbohydrates in a form simple enough to cause dental cavities.
The label term “sugar-free” is not related to the amount of carbohydrates in a food. A food labeled “
sugar-free” may
actually get 100% of its calories from carbohydrates to which you aresensitive!
Sugar has many names, some of which do not sound like sugar. Following is a list of some of the different names for
sugar and sugar analogs. Read all the labels on the foods you eat carefully, as sugar is hidden in the most unexpected
places.

173. 5
Sugars List
Avoid foods which contain sugar earlier than the fifth ingredient.
-OSE SUGAR CANE SYRUP MOLASSES
glucose granulated sugar cane juice crystals maple syrup granules sorghum molasses
dextrose brown sugar dehydrated cane juice maple syrup Barbados molasses
levulose light brown sugar crystals invert syrup blackstrap molasses
maltodextrose
ribose
galactose
xyulose
dark brown sugar
raw sugar
powdered sugar
turbinado sugar
unrefined cane juice
crystals
washed cane juice
crystals unbleached
evaporated
corn syrup
high fructose corn syrup
corn sweeteners
corn syrup
fruit sweetener
FRUIT JUICE
concentrated
fruit juice sweeteners
FRUITSOURCE™
clarified grape juice
fruit nectars
sucrose beet sugar sugar cane juice corn syrup solids
fructose confectioner’s sugar crystals malt syrup
crystalline
fructose
maltose
lactose
invert sugar
fruit sugar
white sugar
lo-sugar
crystallized cane juice
evaporated cane juice
unbleached sugarcane
evaporated cane juice
cane syrup
ribbon cane syrup
sorghum syrup
invert sugar syrup
HONEYpolydextrose low sugar unbleached crystallized hydrogenated
lite sugar
grape sugar
Barbados
sugar maple
sugar
evaporated cane juice
organic dehydrated cane
juice
raw cane
crystals Florida
Crystals™
glucose syrup
heavy, light, or
late syrup
natural syrup
fig, date, or
raisin fruit syrup
rice syrup
brown rice syrup
unfiltered honey
filtered honey
-OL
maltitol
sorbitol
mannito
l xylitol
CARAMEL
caramel
caramel color
monosaccharides
MALT
-DEXTRIN barley malt brown rice sweetener disaccharides
barley extract polysaccharides
Lactodextrin
tapioca dextrin
acetylated
dextrin
amasake
demerara
malt syrup
maltodextrin
malted cereal extract
cereal extract
succanat
rice malt
malt flavoring

174. 6
Protein
Protein sources may be low fat, moderate fat, or high fat. Generally, they contain no carbohydrate. When your food
plan is written, the added fat servings are adjusted to the appropriate amount including the fat in your usual protein
choices. Do not change your fat serving because of your protein servings; rather, use different protein choices each day
or week, creating balance and variety. Choose lean cuts of meat and trim all visible fat. You may leave the skin on
poultry products for cooking, and then remove the skin before eating. Fat free proteins are notpermitted.
You may use processed vegetarian proteins, such as tofu, tempeh, veggie hot dogs, and veggie burgers, as protein
replacements. Check the labels very carefully to be sure that no carbohydrates have been added and to be sure that
there is enough protein to replace the meat serving.
Tofu products vary widely in nutrient content, and available products vary by region. Do notovercook before weighing.
Pork and fresh ham are fine as a meat serving; however, processed ham and smoked hams need to be avoided if they
have sugar added. Check the labels to be sure. Imitation crab and other imitation fish products are not part of the food
plan because of their sugar content.
You may also mix proteins, that is, use one protein for part of your allowance and another for the rest. Weigh proteins
after cooking.

175. 7
Protein List
The proteins in this chart are grouped by category and listedalphabetically.
If there is an ‘x’ under .5:1, this means that .5 ounce of protein by weight is equal to 1 ounce of protein.
Exp: .5 oz of almonds = 1 oz of protein
If there is an ‘x’ under 1:1, this means that 1 ounce of protein by weight is equal to 1 ounce of protein.
Exp: 1 oz of chicken breast = 1 oz of protein
If there is an ‘x’ under 1.5:1, this means that 1.5 ounces of protein by weight is equal to 1 ounce of protein.
Exp: 1.5 oz Morningstar veggie burger = 1 oz protein
If there is an ‘x’ under 2:1, this means that 2 ounces of protein by weight is equal to 1 ounce of protein.
Exp: 2 oz of edamame = 1 oz protein
If there is an ‘x’ under 4:1, this means that 4 ounces of protein by weight is equal to 1 ounce of protein.
Exp: 4 oz of cottage cheese = 1 oz protein
Meat & Protein .5 to 1 1 to 1 1.5 to 1 2 to 1 4 to 1
Beef X
Beef or Chicken sandwich steak(Steak-umm) X
Canadian bacon X
Chicken - canned or shelf-stablepouch X
Chicken - breast, leg, or thigh (noskin) X
Kidney - beef or lamb X
Lamb - including gyro meat X
Liver - beef, calf, orchicken X
Prosciutto X
Pork X
Sausage - bratwurst, Italian sausage,
knockwurst, smoked sausage, and
kielbasa
X
Tuna fish - canned or shelf-stablepouch X
Turkey - deli style X
Turkey or Capon X
Veal X
wild game - venison, rabbit, squirrel,
pheasant, buffalo, ostrich, duck, or
goose
X
Seafood .5 to 1 1 to 1 1.5 to 1 2 to 1 4 to 1
Bass X
Bluefish X
Clams X
Carp X
Catfish X
Caviar X
Cod X

176. 8
Seafood .5 to 1 1 to 1 1.5 to 1 2 to 1 4 to 1
Crab X
Flounder X
Gefilte fish X
Grouper X
Haddock X
Halibut X
Herring X
Lobster X
Lox X
Mackerel X
Monkfish X
Mullet X
Mussels X
Orange Roughy X
Oysters X
Perch X
Pollack X
Salmon X
Sardines X
Sashimi X
Scallops X
Sea Bass X
Shrimp X
Smelt X
Snails X
Snapper – Red orYellowtail X
Sole X
Squid X
Swordfish X
Tilapia X
Tilefish X
Trout X
Tuna X
Cheese *no fat-free .5 to 1 1 to 1 1.5 to 1 2 to 1 4 to 1
American X
Blue X
Brie X
Camembert X
Cheddar X
Cottage Cheese *no more than 8 oz permeal X
Farmer’s X
Feta X
Goat X
Gouda X
Havarti X

177. 9
Cheese *no fat-free .5 to 1 1 to 1 1.5 to 1 2 to 1 4 to 1
Jarlsburg X
Laughing Cow (light or reg) 2 wedges = 1protein X
Mozzarella X
Muenster X
Parmesan X
Provolone X
Swiss X
Ricotta X
Eggs & Egg Equivalents
1 large egg X
2 egg whites + 5 g fat
1/3 cup egg substitute + 5 g fat
Tofu & Vegetarian Options .5 to 1 1 to 1 1.5 to 1 2 to 1 4 to 1
Beyond Meat X
Edamame, shelled X
Edamame, in pod X
Nutritional Yeast X
Tofu – soft & silken X
Tofu – firm, extra firm, super firm – NO
LIGHT TOFU
X
Seitan X
Soy crumbles X
Spirulina X
Tempeh X
Veggie burgers – Morning Star, Better’n
Burgers, Green Giant Harvest, Boca, Gardein
Chick’n Scaloppini or Chick’nFillets
X
Veggie dog X
Nuts *Unsalted & Raw ONLY .5 to 1 1 to 1 1.5 to 1 2 to 1 4 to 1
Almonds X
Brazil nuts X
Butternuts X
Cashews X
Chia X
Flax X
Hazelnuts X
Hemp X
Macadamia X
Peanuts X
Pecans X
Pine nuts X
Pumpkin seeds X
Pistachios X
Sesame seeds X
Soy nuts X

178. 10
Squash seeds X
Sunflower seeds X
Walnuts X
Beans .5 to 1 1 to 1 1.5 to 1 2 to 1 4 to 1
Adzuki X
Black X
Cannellini (white kidneybeans) X
Cranberry X
Fava X
French X
Garbanzo (chick peas) X
Great northern X
Hyacinth X
Kidney X
Lentils X
Lima X
Mung X
Navy X
Pinto X
Soybeans X
Turtle X
Winged X
Yardlong X
Yellow X

179. 11
Fats
Fats are essential to the body for the health of the heart, lungs, and nervous system; many hormones are made from
fats. The structure of the skin, hair, and nails depends on dietary fat sources. You must not eliminate all dietary fat; fats
should comprise 20-30% of calories.
You may use any mixture of fats that totals the number of grams specified on your foodplan.
The fat list is divided into unsaturated and saturated. Emphasize monounsaturated and polyunsaturated fats such as
olive oil, canola oil, and corn oil, in preference to saturated fats. Monounsaturated and polyunsaturated fats are
vegetable in origin and liquid at room temperature, while saturated fats, such as shortening or butter, are animal in
origin, and are solid at room temperature. Most nutrition authorities now recommend complete avoidance of trans
fats, which are made when oils are hydrogenated, because they greatly increase your risk of heartdisease.

180. 12
Fat List
Do not cook with allotted fat. Use cooking spray or fill a spray bottle with olive oil or chicken broth. Use the table below
to determine how many grams, by weight, you will need in order to satisfy 5, 10, or 12 gfat.
Monounsaturated & Polyunsaturated 5 g fat 10 g fat 12 g fat
Margarine 7 14 17
Whipped margarine 10 20 24
Mayonnaise 7 14 17
Oil (canola, corn, safflower, soybean, sunflower, olive,
peanut) 5 10 12
Regular salad dressing (blue cheese,Caesar) 10 20 24
Avocado 28 56 67
Guacamole 38 76 91
Basil pesto 16 32 38
Green olives
small 10 olives 20 olives 24 olives
sliced 32 64 77
Black olives
small 12 olives 24 olives 29 olives
medium 10 olives 20 olives 24 olives
jumbo 8 olives 16 olives 19 olives
sliced 32 64 77
Kalamata olives 7 olives 14 olives 17 olives
Saturated 5 g fat 10 g fat 12 g fat
Bacon 12 24 29
Turkey bacon 45 90 108
Turkey Pepperoni 38 76 90
Beef or Pork Pepperoni 12 24 28
Butter 7 14 17
Whipped butter 6 12 14
Sour cream 30 60 72
Reduced fat sour cream 52 104 125
Regular cream cheese 15 30 36
Whipped cream cheese 25 50 60
Light cream cheese 30 60 72
Mascarpone cheese 11 22 26
Unsweetened coconut flakes 7.5 15 18
Coconut milk 37 74 89
Light coconut milk 89 178 214

181. 13
Use the table below to determine how many grams of nuts or seeds you will need in order to satisfy 5,
10, or 12g fat.
Examples: 10 g of almonds by weight = 5 g of fat
7 g of pecans + 8 g of walnuts by weight = 10 g of fat
Nuts & Seeds *Unsalted & Raw ONLY 5 g fat 10 g fat 12 g fat
Almonds 10 20 24
Brazil nuts 8 16 19
Butternuts 9 18 22
Cashews 12 24 29
Chia Seeds 16 32 37
Flax seeds 12 24 28
Hazelnuts 8 16 19
Hemp Seeds 11 22 26
Macadamia 7 14 17
Peanuts 10 20 24
Pecans 7 14 17
Pine nuts 8 16 19
Pistachios 11 22 26
Pumpkin Seeds 23 46 56
Sunflower seeds 10 20 24
Sesame seeds 10 20 24
Walnuts 8 16 19

182. 14
Fats – Alternate Method
Use this alternate method to calculate fats using tablespoons andteaspoons.
Monounsaturated & Polyunsaturated 5 g fat 10 g fat 12 g fat
Margarine 1 tsp 1 Tbsp 1 Tbsp + 1 tsp
Whipped margarine 2 tsp 1 Tbsp + 1 tsp 1 Tbsp + 2 tsp
Mayonnaise 2 tsp 1 Tbsp 1 Tbsp + 1 tsp
Oil (canola, corn, safflower, soybean, sunflower, olive,
peanut) 1 tsp 2 tsp 1 Tbsp
Regular salad dressing (blue cheese,Caesar) 2 tsp 1 Tbsp + 1 tsp 1 Tbsp + 2 tsp
Avocado 2 Tbsp 4 Tbsp 5 Tbsp
Guacamole 2 Tbsp 4 Tbsp 5 Tbsp
Basil pesto 1 Tbsp 2 Tbsp 2 Tbsp + 2 tsp
Green olives
small 10 olives 20 olives 24 olives
sliced 2 Tbsp + 1 tsp 4 Tbsp + 1 tsp 5 Tbsp + 1 tsp
Black olives
small 12 olives 24 olives 29 olives
medium 10 olives 20 olives 24 olives
jumbo 8 olives 16 olives 19 olives
sliced 2 Tbsp + 1 tsp 4 Tbsp + 1 tsp 5 Tbsp + 1 tsp
Kalamata olives 7 olives 14 olives 17 olives
Saturated 5 g fat 10 g fat 12 g fat
Bacon 1 slice 2 slices 2 ½ slices
Turkey bacon 2 slices 4 slices 5 slices
Turkey Pepperoni 1 oz 2 oz 3 oz
Beef or Pork Pepperoni .5 oz 1 oz 1.25 oz
Butter 2 tsp 1 Tbsp 1 Tbsp + 1 tsp
Whipped butter 2 tsp 1 Tbsp + 1 tsp 1 Tbsp + 2 tsp
Sour cream 2 Tbsp 4 Tbsp 5 Tbsp
Reduced fat sour cream 3 Tbsp + 2 tsp 7 Tbsp + 1 tsp 8 Tbsp + 2 tsp
Regular cream cheese 1 Tbsp 2 Tbsp 2 Tbsp + 2 tsp
Whipped cream cheese 1 Tbsp + 2 tsp 3 Tbsp 3 Tbsp + 2 tsp
Light cream cheese 2 Tbsp 4 Tbsp 5 Tbsp
Mascarpone cheese 2 tsp 1 Tbsp + 1 tsp 1 Tbsp + 2 tsp
Unsweetened coconut flakes 1 Tbsp + 2 tsp 3 Tbsp 3 Tbsp + 2 tsp
Coconut milk 1 oz 2 oz 2.4 oz
Light coconut milk 3 oz 6 oz 7 oz

183. 15
Numbers listed below are pieces, unless otherwise noted.
*Use heaping Tbsp and tsp for walnuts and butternut; all others should belevel
**Counts are for the whole nut
Nuts & Seeds 5 g fat 10 g fat 12 g fat
1 oz protein
(.5 oz by wt)
Almonds 8 17 20 12
Brazil nuts 2 3 4 4
Butternuts* 1 Tbsp 2 Tbsp 2 Tbsp + 2 tsp 2 Tbsp
Cashews** 6 11 14 8
Chia Seeds 1 Tbsp 2 Tbsp 2 Tbsp + 2 tsp 1 Tbsp
Flax seeds 1 Tbsp 2 Tbsp 2 Tbsp + 2 tsp 1 Tbsp + 1 tsp
Hazelnuts 6 12 14 13
Hemp Seeds 2 tsp 1 Tbsp + 1 tsp 2 Tbsp 1 Tbsp + 1 tsp
Macadamia 5 9 11 9
Peanuts** 11 21 26 15
Pecans (halves) 5 9 11 8
Pine nuts 2 tsp 1 Tbsp 1 Tbsp + 1 tsp 1 Tbsp + 1 tsp
Pistachios (shelled) 16 31 38 24
Pumpkin Seeds 2 Tbsp 4 Tbsp 5 Tbsp 1 Tbsp + 1 tsp
Sunflower seeds 2 tsp 1 Tbsp 2 Tbsp 2 Tbsp
Sesame seeds 2 tsp 1 Tbsp 2 Tbsp 1 Tbsp + 2 tsp
Walnuts* 1 Tbsp 2 Tbsp 2 Tbsp + 2 tsp 2 Tbsp

184. 16
Cereals, Carbohydrates and Grains
Weigh carbs, such as rice, after cooking. Try some carbs that are new to you, and experiment with seasonings, sauces,
and flavors.
One ounce of cold cereal or uncooked hot cereal is equivalent to 3 carbs. Weigh hot cereal, such as oatmeal, before
cooking; the amount of water absorbed can vary greatly and will change theweight.
Rice cakes are acceptable but since they have fewer nutrients, you may feel hunger quickly after eatingthem.

185. 17
Cereals, Carbohydrates and Grains List
1 oz of cereal = 3 oz carbs
All complex carbs and grains are 1:1, unless otherwise noted, such as pumpkin (2:1)
Exps: 1 oz barley = 1 oz carb
2 oz pumpkin = 1 oz carb
Cold Cereals Hot Cereals Complex Carbs/Grains
Uncle Sam’s Cereal oat bran amaranth
shredded wheat oatmeal barley
spoon-sized shredded wheat rolled oats beans
shredded wheat and bran Irish oatmeal buckwheat
Erewhon Corn Flakes cream of brown rice bulgur
puffed brown rice cream of whole rye corn: white, yellow, sweet, corn on cob (6
in long)
puffed rice kasha farro
puffed corn buckwheat groats green peas
puffed millet barley buds hummus
puffed barley creamy rice kamut
puffed kashi rye wheat berries kasha
puffed wheat rye berries lentils
puffed whole wheat 7 grain, rye flakes, barley flakes millet
Wheat Germ Pritkin Hearty Multigrain HotCereal parsnips
Kashi Pilaf Erewhon 12 grain hot cereal plantain
Seven Grain Kashi Cereal millet potatoes: white, gold, russet, Yukon
quinoa pumpkin – canned (2:1)
hominy (yellow corn grits) quinoa
wheat hartz rice: basmati, brown, Creole, Jasmine,
pecan, texmati, and wild rye berries (no
yellow, white or red rice)
wheat bran spelt
Wheatena split peas
whole corn grits black-eyed peas
sweet potato
wheat berries
ALL winter squash 2:1: acorn, butternut,
hubbard pumpkin, spaghetti
yams
yucca

186. 18
Abstinent Cracker List
Crackers may be used at a maximum of once per day. Calculate crackers in terms of calories per ounce, versus weight.
Exceptions on flavors are listed below. All other flavors arepermitted.
Ezekiel Wraps
Wrap Itz – 100% Stone Ground Whole Wheat ONLY
Rice Cakes – brown, plain, or lightly salted ONLY
Ryvita Crackers – no Sesame Rye
Ry Krisp – no Sesame
Wasa – no Sesame or Light Rye
Mary’s Gone Crackers – no Super Seed
Abstinent Prepared Frozen Carbs
Dr. Praeger’s spinach or broccoli pancakes
2 pancakes = 3-4 oz carb
Alexia’s Garlic Rosemary & Olive Oil Roasted Potatoes
1:1 (i.e.: 3 oz potatoes cooked = 3 oz carb)
Additional Carbs
Arrowroot is a white powder extracted from the root of a West Indian plant, Marantha arundinacea. It looks and feels
like cornstarch. Arrowroot may be used as a carb, to make crepes, or it may be used as a condiment to make fruit jellies
or sauces.
• As a carb, 1 Tbsp of arrowroot = 1 oz cooked carb
• As a condiment, up to 3 tsp “free” are permitted per day for use in arecipe.
Chestnuts are unique compared to other nuts because of their low fat and high moisture content. They are comprised
primarily of carbohydrates, making them more nutritionally akin to a grain. Chestnuts can be counted as carb using a
1:1 ratio.
• 1 oz chestnuts = 1 oz carb
1 oz carb = 40 calories
3 oz carb = 120 - 150 calories
4 oz carb = 160 - 180 calories

187. 19
Fruits
All of the calories in fruit come from the fruit sugar named fructose. Fructose is digested and absorbed as quickly as any
sugar; after absorption it is sent to the liver to be converted into glucose, glycogen, and triglycerides. If you eat fruit
alone or on an empty stomach, you may find yourself craving or extremely hungry 60-90 minutes later. It’s
recommended that you eat fruit with protein or milk servings or with your meal to slow down the absorption of the
sugar.
Measuring fruit servings
Fruit cores, peel, and seeds add very little weight. If you choose, you may weigh fruit in the grocery store to 1 oz more
than your prescribed weight per piece of fruit. Some fruits are more concentrated than others, and are measured to ½
the amount required by your food plan. For example, if you wish to eat grapes and are required to eat 6 oz of fruit, you
would weigh out 3 oz of grapes. Additionally, when weighing out frozen fruit, add 1 more oz in weight to account for
the ice.
Canned Fruit
Weigh or measure canned fruit to your food plan specifications. Use only fruit that is packed in water or its own juices.
If packed in its own juices rinse and drain 3 times before consuming. Use applesauce which is natural and unsweetened,
but avoid the “No Sugar Added” applesauce because it contains added fruit concentrate. Applesauce may be weighed
or measured to your food plan’s specifications. Do not use canned fruit sweetened with Splenda, unless verified by the
nutritionist. Fruit juices and dried fruit are not permitted on the foodplan.

188. 20
Fruit List
The fruits in this chart are listedalphabetically.
If there is an ‘x’ under .5:1, this means that .5 ounce of fruit by weight is equal to 1 ounce of fruit.
Exp: .5 oz of grapes = 1 oz of fruit
If there is an ‘x’ under 1:1, this means that 1 ounce of fruit by weight is equal to 1 ounce of fruit.
Exp: 1 oz blueberries = 1 oz of fruit
Fruit .5 to 1 1 to 1
Apples X
Applesauce X
Apricots X
Bananas X
Blackberries X
Blueberries X
Boysenberries X
Cherries (20) X
Clementines X
Cranberries X
Figs X
Fruit Cocktail X
Grapes X
Goji berries (frozen) X
Grapefruit X
Kiwi X
Mango X
Mandarin Oranges X
Melon (honeydew, cantaloupe,casaba) X
Nectarines X
Oranges X
Papaya X
Peaches X
Pears X
Persimmon X
Pineapple X
Plums X
Pomegranate X
Raspberries X
Strawberries X
Tangelos X
Tangerines X
Watermelon X

189. 21
Vegetables
5 Reasons to Eat Vegetables
(1) They contain an incredible variety of vitamins, minerals, and other nutrients that are not found
in other foods.
(2) They are low in sodium and are excellent sources of dietaryfiber.
(3) They contain chemicals that may slow the development of cancer cells at a variety of stages of
its development.
(4) They give you the opportunity to chew! And their volume makes you feelfull.
(5) They slow down the absorption of the other foods you eat, so your meal lasts longer.
Choose a variety of vegetables to maximize their nutritioncontent.

190. 22
Vegetable List
alfalfa sprouts * Weigh artichokes whole, after cooking, to twice your foodplan
*artichoke
specifications.
artichoke hearts
asparagus
With Caution:
baby corn (canned)
V-8 juice**
bamboo shoots
tomato juice**
beans (yellow, green, wax, butter, or Italian)
vegetable juice**
bean sprouts
* *1 cup (8 oz) may be substituted for 4 ounces of vegetables.You
may only use V-8 juice during travel greater than 8 hours orillness.
beets Speak with your dietitian beforeusing.
bok choy Vegetables can be used for snack 1X/day (instead of yourfruit)
broccoli Vegetables may not be made into“chips”
brussel sprouts
cabbage (red, savoy, green, purple, Chinese, orbutterbur)
carrots
cauliflower
celery
celeriac
chicory
cucumbers
dill pickles
eggplant
fennel
garlic
greens (such as beet, Swiss chard, chicory, escarole,mustard,
collard, turnip, dandelion, kale, endive, watercress,or
spinach)
jicama
snow peas
sugar snap peas
tomatoes (includes cherry tomatoes and grapetomatoes)
turnips, yellow or white
water chestnuts

191. 23

192. 24
Milk and Yogurt
Milk is a powerhouse of whole protein, calcium, B vitamins, minerals, and vitamin D. It is a well-balanced source of
proteins, fat, and carbohydrate.
When you choose milk and milk products, they will always contain carbohydrates. Read labels and compare them with
plain low fat milk to be sure that no sweeteners have been added. Check for starches, gums, stabilizers, and other
additives to which you may be sensitive. Choose non-fat or low-fat milkproducts.
Lactose intolerance means that the body is unable to digest the carbohydrate in milk named lactose. If you are lactose
intolerant, one option is to try Lact-Aid milk or Lact-Aid or Lactase pills or drops to change the carbohydrate into a form
you can handle.
Another option is to use a milk substitute made from soy, rice, oat, barley, or a combination of grains. Read these labels
carefully; these products often have sugars or other carbohydrates added to them and may have much less protein than
cow’s milk.

193. 25
Milk List
Milk may not be substituted for protein at lunch or dinner.
1 cup milk, skim or 1% or 2%
1 cup low-fat buttermilk
1/2 cup evaporated skim milk
1/3 cup non-fat dry milk powder
6 -8 oz of plain or Greek yogurt (fat free or low fat)
1 cup soy milk *
1 cup soy rice milk*
1 cup sweet acidophilus milk
1 cup goat’s milk
3/4 cup kefir
*Be certain that these products are calcium fortified, have as much protein as regular milk,
and have no added sugars.

194. 26
Flour/Starch
This basic food plan removes all flour and flour-containing foods. Because flour is made of long chains of sugar
molecules, which are quickly absorbed, your body’s reaction to flour may be similar to its reaction to sugar. Additionally,
your sensitivity to flour may increase when sugar is removed. If you are sensitive to a particular type of flour, you are
likely to be sensitive to all flours - wheat, rye, oat, corn, barley, soy, spinach, millet, artichoke or kidney bean flour.
People vary widely in their sensitivities to flours, and all food sensitivities can change over time. It is recommended that
you remove these foods at the beginning of your recovery. After a period of abstinence, you may wish to discuss this
matter with your dietitian.
White flour also may be called wheat flour, enriched flour, or unbleached enriched wheat flour. Durham semolina and
red winter wheat are also names for flour. The name for corn flour is cornmeal; foods made with this product are flour
foods. Avoid all these foods.
Corn starch, wheat starch, tapioca starch, and modified food starch are not sugars but are such highly refined flours
that the body frequently reacts to them as though they were sugars. Avoid products in which they are listed before
the fifth ingredient.
On food labels, manufacturers must state each ingredient in the original form with which they began their manufacture
of the food. For instance, if a manufacturer bought whole corn and ground it into corn flour the manufacturer can list
“corn” on the label. Corn chips, tortillas, and similar products are all made with corn flour. Rice and barley pastas are
also made from flours. Read labels carefully and use your intuition, your common sense, and good judgment. Ask for
help from your nutritionist whenever you need it.

195. 27
Sweeteners
Five non-nutritive artificial sweeteners are approved by the FDA for use assweeteners:
• Saccharin - sold as Sweet ‘N Low, Sweet Twin, Sweet ‘N Low Brown,Nectasweet
• Aspartame - sold as NutraSweet, Equal, or Sugar Twin
• Acesulfame K - sold as Sunett, Sweet & Safe, Sweet One
• Sucralose - sold as Splenda
• Stevia - sold as Sweet Leaf, Stevia in the Raw, Better Stevia
• Eryrthritol - sold as Truvia, PureVia
All are much sweeter by volume than sugar. Because of this they are sold in packets with an extender, or bulk-adding
product like dextrose or maltodextrin. These extenders are sugars or sugar analogs - other types of sugar-like foods. The
current trend is to blend these high intensity sweeteners with each other or with sugars or sugar analogs to create the
desired sweetness, texture, and consistency for the product. Depending on your individual sensitivities, the sweeteners
themselves can affect many body processes, or the sweet taste may call up memories of binge or trigger foods, or of
your past binge eating experiences.
If you are sensitive to one or the other of these products, you may notice increased anxiety, irritability, headaches, and
cravings after using it. If you are having unexplained cravings or difficulty following your food plan, look at your use of
sweeteners. If you suspect they may be causing problems for you, removethem.
Check with your doctor about all of these products if you are pregnant or lactating or have other medical problems
which may be affected by them.
If you find yourself mixing sweeteners or using more than 6 packets or “
stretching” (counting, waiting for the next one,
or mixing to sneak in an extra one), then you need to avoid them.
Daily Allowance & Guidelines
• Maximum of 6 packets
• Maximum of 2 packets per food or beverage item
• No liquid sweeteners (ie: Stevia drops)

196. 28
Sugar-Free Gum, Mints and Artificially Sweetened Drinks
Sugar-Free Gum and Mints: All sugar-free gum and mints contain sugar alcohols (sorbitol, maltitol, xylitol, etc.), plus
NutraSweet (aspartame) or other artificial sweeteners. Sugar-free gum and mints are not recommended for regular use,
because the sugar alcohols or the concentrated sweeteners can be triggering. You may have no more than 5 mints or 5
sticks of sugar-free gum per day. If you find yourself having used all 5 sticks or mints in the first half of the day,
eliminate them entirely. If you find yourself with more than one stick of gum or mint in your mouth, eliminate all gum
or mints.
Artificially Sweetened Drinks: You may have up to 24 oz of an artificially sweetened drink per day. This includes all
Crystal Light, diet sodas, and diet Snapple products. You may have up to 1 Crystal Light packet, or similar product, per
day. Squeeze liquid flavored beverage mixes are not permitted.
Caffeine: Caffeine stimulates the central nervous system and can produce many effects throughout the body. Primarily,
it increases heart rate and the capacity for muscular work. If you are tired, sleepy, or bored, caffeine may make you feel
more wide-awake and able to focus on mental and manualtasks.
Excessive caffeine consumption may lead to anxiety, restlessness, irritability, sleep disorders, headache, and heart
palpitations. You may also have troublesome cravings and increased hunger with excessive caffeineuse.
A reasonable amount of caffeinated beverages would be two 8 oz cups per day. Work with your dietitian to find the
amount that is best for you.
Fluids: Your weight and sense of well-being are affected by the amounts of fluids you drink. Water is vital for every
chemical reaction of digestion and metabolism, for joint regulation, and for brain function. You do not have to drink
only water. You may also choose seltzer, flavored seltzer, sparkling water, or decaffeinated herbal teas.
Estimates currently vary about the amount of water needed. Many authorities say that we should drink 8 to 10 cups of
fluid per day, others say more or less. You may need even more than 10 cups per day, especially in early recovery, to
wash out high sugar, high fat, or high salt foods, or your binge or trigger foods and their effects, and to stabilize blood
volume. People with a lot of weight to lose often need additional fluids - some authorities recommend adding 1 cup of
fluid for each 25 pounds over normal body weight. Drink extra fluids also if you exercise briskly or if the weather is hot
and dry. Create a pattern for fluid intake to distribute your fluid intake evenly through theday.

197. 29
Beverages, Condiments and Sauces
Artificial Sweeteners: 6 packets per day, not more than 2 packets permeal.
Artificially Sweetened Drinks: 24 oz. per day of artificially sweeteneddrinks
• diet soda, diet Snapple or any water flavored with artificialsweetener
• 1 packet per day of Crystal Light or equivalent per 16 oz of water
Broth: 2 cups of broth or consommé per day
• Beef, chicken, or vegetable. Canned broth must not have sugar or flour products in the first fiveingredients
Butter Spray: 10 sprays per meal
Chopped Vegetables: 4 oz chopped vegetables per day for flavoring otherfoods
Coffee: 2 cups of 8 oz of coffee per day
Condiments: sugar and alcohol-free, no more than 3 condiments permeal
• 2 Tbsp of ketchup, mustard, hot sauce, soy sauce, tamari,vinegar
• 1 tsp of miso, wasabi, anchovy paste, horseradish, pimentos, alcohol-free flavoringextracts
• 2 Tbsp of Heinz Reduced sugar Ketchup sweetened with Splenda = 1 Splenda packet
• 2 Tbsp of Walden Farms calorie free, sugar free dressings *Must be approved by theNutritionist
• up to 3 tsp of arrowroot as a thickener for fruit filling orsauces
Dairy & Alternative: 4 oz of milk OR unsweetened almond milk OR yogurt plus 1 egg white for coffee and/or food
preparation
Flavors: Sugar free syrup must be approved by the Nutritionist before initialuse
Fruit Condiments: ½ lemon or lime slice up to six times a day for tea orseltzer
Herbs and Spices: 2 tsp of any herb, spice, or herb mixture you choose per meal plus any herb, spice, or mixture as
directed by a recipe
• 1 tsp table salt per day
Sauces: ½ cup sauce per meal
• Sugar-free barbecue sauce, picante sauce, tomato sauce, salsa
• less than 2 g fat and less than 60 calories per half cup

198. 30
Metric Equivalents
Equivalents for Different Types of Ingredients
Standard
Cup
Fine
Powder
Grain Granular Liquid
Solids
Liquid
1 140 g 150 g 190 g 200 g 240 ml
3/4 105 g 113 g 14 3g 150 g 180 ml
1/2 70 g 75 g 95 g 100 g 120 ml
1/3 47 g 50 g 63 g 67 g 80 ml
1/4 35 g 38 g 48 g 50 g 60 ml
Dry Ingredients by Weight
To convert ounces to grams multiply the
number of ounces by 30.
1 oz = 1/16lb = 30g
4 oz = 1/4lb = 120g
8 oz = 1/2lb = 240g
12 oz = 3/4lb = 360g
16 oz = 1 lb = 480g
Liquid Ingredients by Volume
3 tsp = 1 tbsp = 1/2 fl oz = 15 ml
1 pt = 2 cups = 16 fl oz = 480 ml
1 qt = 4 cups = 32 fl oz = 960 ml

199. 31
Meal Ideas
• Chicken fried rice with egg beaters and veggies
• Chicken/Tuna salads with rye crisps or atop salad, dressing, veggies,beans
• Salsa Chicken or Boca (with cheese)and refried black beans with salad, lettuce shreds orvegetables (peppers)
• Chicken/tuna/tofu stir fry w/ lettuce cups, crushed cashews, vegetable mix (celery, water chestnuts, red pepper,
onion, etc.), and rice and/or baby corn.
• Tofurky warmed in skillet with marinated or roasted vegetables and baked potato with side salad, splitting dressing
between turkey and salad or butter for potato
• ¾ C omelet with 4 oz veggies, 3 oz fruit in oatmeal with butter in oats and eggs, or Newman’s garlicdressing
• Tuna or salmon steak marinated and grilled with balsamic vinegar and garlic, green beans and rosemary roasted
potatoes
• Grilled chicken with garlic broccoli or spinach, tossed with pecans and dressing, served with corn on the cob, rice or
potatoes
• Roasted red peppers stuffed with rice, egg white, chopped onions, garlic, Newman’s garlic olive oil and tofu
• Tuna melt atop rice cakes with side salad and dressing ornut
• Tofurky atop rice cakes with tomatoes pickles and cheese slices and side salad; dressed salad and drizzled
“sandwich”
• Lentil soup (8 oz bean, 2 oz onion/celery, Newman’s dressing) with potato/rye crisp/rice cake/rice and side salad
• Tofu/Chicken & rice soup with carrots, celery, tomato, broccoli and oliveoil
• White bean puree with spinach, tomato, onion, side salad (or not), and rye crisps (ornot)
• Carrot puree with yucca chunks, side salad and chicken (curry recipe) (or rye crisps) andwalnuts
• Tofu grilled with tomatoes and onions atop greens, rye crisps and nut ordressing
• Boca salad with corn and/or rice, atop lettuce shreds, red/pepper blend, onions, cheese and ranch or Caesar in
blend or on top
• Boca & refried bean “pate” in lettuce cups with dressing/walnut, peppers andsalsa

200. 32
Quick Reference Guide
• No fat-free cheese of any kind, including cottage cheese
• Fat-free yogurt and milk is OK
• Cottage cheese is 4:1
• Laughing Cow cheese - 2 wedges = 1 protein for both light andregular
• Beans as protein 2:1 as carb 1:1
• All nuts and seeds as protein .5:1 as fat, check the label for fatgrams
• 2 egg whites + 5g fat = 1 protein
• 1/3 cup egg substitute + 5g fat = 1 protein
• Hummus is a carb 1:1
• Pumpkin and all winter squash are carbs that are2:1
• Fruit may replace vegetable in a recipe 1x per week
• Add 1 oz when weighing frozen fruit
• Vegetable for snack only 1x per day
• Crackers no more than 1x per day
• No more than 3 loaves per week as a meal
• No more than 6 packets of sweetener per day
• No more than 5 pieces of gum or mints per day
• No squeeze liquid sweeteners or liquid beverage mixes
• Add 2 oz to raw vegetables if weighed before cooking
• Add 1 ½ oz to ANY raw protein if weighing beforecooking
o Exp: 3 oz needed = 4 ½ oz raw white fish + 1 ½ oz raw fish = 6 oz total rawweight
• Avoid foods which contain flour or sugar before the 5th
ingredient
• Avoid foods that contain three or more sugars, even below the fifthingredient
• No dessert flavored coffees (ie: Godiva Chocolate or StrawberryShortcake)
• Nut and vanilla flavored coffees are acceptable.
• Look for the buzz words flour and starch on food labels and AVOID these foods; wheat is OK, unless you have
been advised to follow a gluten-free plan
• Coffee-house guidelines:
o Must be approved and included on pass
o ONLY hot or iced: regular or decaf coffee, unsweetened tea
o Add milk and sweetener to your own beverage-- should not be added bybarista
o No other beverages are permitted (ie: lattes, cappuccinos, sugar freesyrups)