Lepage Associates Newsletter
Mental Health Matters
February 2011
Lepage Associates
Call: (919) 572-0000
In This Issue
Children and Body Image
Eating Disorder Assessments
Children's Health
Bariatric Surgery



Please click on each group for a flier with complete information to include description,
Dr. Tina Lepage Answers Questions from Carolina Parent magazine on


(1) Given today's powerful and omnipresent cultural and media stereotypes about bodies and beauty, do you think parents have any control over how children and adolescents feel about their bodies? Please explain.

Actually, parents have a lot of control over how children and adolescents feel about everything, their bodies included. For example, studies have found that the messages that parents give to their child have more influence on the child's thoughts and behaviors than messages they get from peers. So parents can help combat unhealthy media and cultural messages about body image by providing healthy messages within the home.

(2) In what ways do a parent's body image "issues" affect and/or determine those of his or her children? Is it more common for children to have the same or different body image issues as their parents?

In terms of overall self-image, on an internal level children see themselves as half mom and half dad. Thus if mom or dad has a poor body image, the child is at risk for having concerns about his or her own body, and for having low self-esteem around this issue.More specifically, children identify closely with the same sex parent in terms of their vision of what it means to be a man/boy or woman/girl. Since girls are more vulnerable to body image issues (due to societal pressures), and girls take their primary cues from their mom's attitude about body image stuff, it is especially important for moms to reflect in their words and actions a healthy attitude about their bodies. 

Conversely, if mom and dad have a positive and healthy body image, the child is more likely to feel good about his or her own body, even in the face of cultural and media images that hold up unrealistic and sometimes even unhealthy body images.  However, even with the best body images within the home, parents do need to also provide information to counteract the media and culture. 

(3) What are the keys to establishing/nurturing a child's healthy body image? How early should parents start? Is this a planned process or does it just happen? There is both some planning and "it just happens" around nurturing a positive body image for your child.  The "it just happens" part is what I spoke of above, wherein the parents' body images have an effect on the child's developing sense of self. 

In terms of when to start, it is never too early to nurture a positive body image (and positive self-image overall), though the key is to not have a high focus on the body and instead chose things that flow naturally into conversation.  Here are some hints: (1) refrain from making negative comments about people's bodies in general, and instead focus on the positive and on compliments versus tearing people down, (2) focus on health versus body size, for example, talk about healthy eating versus dieting and exercising for heart and body health versus to lose weight, (3) institute healthy eating and exercise into your family routine, (4) talk about looking healthy versus looking skinny, thin or fat, and (5) compliment your child regularly.

(4) Thinking specifically about ages 10-14, what are the major body image issues and how can parents best support a healthy attitude?

By this age of 10-14, children are very aware of the societal pressure to be thin and attractive, and this includes both boys and girls. The major body image issue for girls is thinness, which can be very difficult to deal with at this age as puberty sets in. This is also an issue for boys, and though there is less pressure to be "rail thin," there is still pressure to be thin in general and to be "good looking." The second major issue is more a broad area of the pressure to be attractive, which goes beyond the issue of thinness to things like nose size, acne, wearing clothes that are "in," etc. 

Parents can support a healthy attitude by (1) having a healthy body image themselves, (2) having a healthy family lifestyle, (3) regularly providing information to counteract what the children see in the media, and (4) teaching the importance of character, personality, and accomplishments over external looks (for example, focusing more on compliments and positive feedback around positive character behaviors, such as helping a friend, doing one's chores, trying one's best at school, etc., and accomplishments, such as learning to ride a bike, or doing well in school, etc.).



Monthly Reader

Each month we will recommend a book that someone at our practice has found useful.

This month's book is:
Eating In The Light
of The Moon
How Women Can Transform Their Relationship with Food


Anita Johnston, Ph.D.
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Our new weekly area to visit for thought provoking ideas and tips to live life to the fullest.


INFORMATION FOR ATTORNEYS, MENTAL HEALTH PROFESSIONALS, AND FINANCIAL PROFESSIONALS: There is a training being held in Chapel Hill, NC for any of you who might be interested. Continuing education credits have been approved. Collaborative divorce is a process by which these professionals help spouses divorce in an amicable manner, with a focus on protecting the emotions of all children and adults involved. If you ever work with divorcing people in your practice, this training would be highly beneficial to both building your skills and expanding your practice area. To learn more about this training click below and download the Registration Form for the March 2011 Chapel Hill training.





In this Special Issue on Eating we address overeating, under-eating, and purging among all ages, and discuss bariatric surgery. In addition parents will want to read the Q&A about children and body image. We all must eat ! and many Americans struggle with healthy eating; each of you has likely known someone with one of the issues discussed here today.


Comprehensive Help for

 Unhealthy Eating Patterns:

Targeted Assessment

& Effective Treatment


Wondering if you or a loved one is struggling with an eating disorder? Curious about the impact of possible disordered eating on your ability to regulate emotions, manage social interactions, and/or perform tasks of daily living? If you are hoping to overcome not just body image concerns and problematic eating styles but also to gain a more insightful perspective of what motivates these behaviors for yourself or your loved one, a specialized assessment can help.


Lepage Associates is now offering Comprehensive Eating Disorder Assessments which assess all the above mentioned issues.


What is a Comprehensive

Eating Disorder Assessment?


A comprehensive eating disorder assessment is the first step in identifying if eating patterns are unhealthy (such as in anorexia, food restriction, bulimia, binge-eating, or overeating), and the resulting recommendations provide a clear, individualized path for treatment and improvement. The assessment includes an in-depth clinical interview covering psychological, medical, and, if applicable, substance abuse history by a psychologist who is highly trained in and specializes in eating disorders. Family dynamics and past patterns of health, food, weight and exercise additionally will be assessed to aid you in developing a stronger sense of how to best navigate future therapeutic programming.


Our assessment also involves specific eating disorder and body image testing tools, which provide accurate and precise information about one's risk for specific eating disorder symptoms and body image vulnerabilities. Finally, because disordered eating not only affects one's physical presentation but also mood, thoughts, and feelings, the comprehensive eating disorder assessment provides you with information regarding your ability, comfort level, and strategies for managing emotions and interacting with others. When emotion regulation and interpersonal effectiveness skills are areas of concern for our clients, Lepage Associate psychologists are well versed in providing a safe and secure therapeutic setting for you to process these challenges and learn and practice new skills while concurrently addressing any unhealthy eating patterns.


Comprehensive Eating Disorder and combined Substance Abuse Assessment:


If you believe you or your loved one may also be struggling with substance abuse issues, Lepage Associates can supplement the Comprehensive Eating Disorder Assessment with measures aimed at gaining a better understanding of what ties these behaviors together with substance abuse. It is actually quite common for women and men to struggle with both disordered eating and alcohol or drug abuse. In a sense, these actions may be fueled by a desire to cope with unfavorable feelings, distressing thoughts, and difficult life circumstances. When combined, the Comprehensive Eating Disorder and Substance Abuse Assessment provides an extremely thorough and dynamic conceptualization of what life "looks" like for the struggling individual. Having worked with many clients struggling with these comorbid diagnoses, they often report feeling misunderstood and even initially unaware themselves of how much pain they were in. Our assessment process can jump start the therapeutic process when the individual or their loved ones do not seem to know where to turn or seem to have hit many dead ends regarding treatment in the past. Recommendations stemming from the evaluation are designed to be practical and targeted toward immediate symptom relief and long-term stabilization.


Please contact us at 919-572-0000 to speak with a doctor for more information, or email tlepage@lepageassociates.com.




The Importance of Early Intervention

on Your Child's Health


We often think of eating disorders/disordered eating as an adolescent or adult problem, but they can occur in young children, too, and the health complications can be quite harmful. Studies have shown the age at which children have been concerned about their body size and body image has been declining. Also children of any age may overeat in our society of fast and processed food, and children of any age may use eating as emotional comfort or as a means to exert control. Thus even elementary school children can need help with disordered eating. The following symptoms are associated with food restriction (which can result in malnourishment and affect healthy development), or over-eating and binge-eating. Physical symptoms include weight loss, weight gain and obesity, intolerance to hot or cold temperatures, dehydration, amenorrhea (irregular or absent menstruation), lanugo (fine layer of hair-like "peach fuzz"- growing over arms, chest, face, and back in order to insulate the body), electrolyte imbalance, calluses on hands, dizziness, fatigue, sore throat, tooth decay, mouth ulcers, and tension headaches. Chronic emotional distress, lower self-esteem, anhedonia (loss of pleasure in activities), anxiety, and peer victimization are common psychological factors that both underweight and overweight children and adolescents often experience.  


Potential difficulties that require early intervention:

1.    Eating habits tend to be secretive as they are associated with guilt and shame.

2.    Lack of resources (i.e. time, money) to obtain nutritious foods.

3.    In comparison to adults, children and adolescents are not as likely to view their eating behaviors as problematic; they are also less aware of the short and long term health effects of disordered eating/eating disorders.

4.    Children and adolescents are less likely to ask for help because they view their behaviors as either necessary or even helpful.

5.    With regards to food restriction, adults may think that the child or adolescent is merely going through a passing stage and believe it is best not to intervene.

6.    Adults are not sure how to intervene and are often criticized or treated with hostility by their child if they do try to intervene.


What to look for:

1.    Restricted food intake.

2.    Eating excessive amounts of food past the point of fullness (either following a period of restriction or following a period of normal eating).

3.    Secretive eating.

4.    Engaging in food rituals (i.e. taking an excessively long time to eat food because time is spent cutting up food into tiny pieces, rearranging the food on the plate, hoarding foods, chewing food but then spitting it out).

5.    Cooking for others and not eating the food.

6.    Excessive time spent reading cook books and dieting tips.

7.    Increased irritability, sadness, or distress around mealtimes.

8.    Drenching foods in fat free/low calorie condiments (i.e. mustard, vinegar).

9.    Frequent weighing of oneself.

10.Excessive exercise.

11.Wearing extremely tight fitting clothes to show off body or wearing extremely baggy clothes to hide body.

12.Going to the bathroom after most meals.

13.Increasingly isolated behaviors.

14.Denial of hunger despite severe food restriction.

15.Expressions of guilt or shame after eating.


What you can do: The earlier the intervention, the greater likelihood of establishing healthy and adaptive eating habits.

1.    Work together as a family by trying to approach the problem with a team effort.

2.    Don't blame yourself or your child; disordered eating and eating disorders have many causes and parents are often paralyzed by fears that they "did something to cause the problem."

3.    Take care of yourself and reflect on your own values, beliefs, views regarding food and body image.

4.    If necessary, create a treatment team (child, parents, therapist, dietician, personal trainer, etc.).

5.    Try not to label foods as "bad" or "good" and encourage your child to try a variety of foods that can "fuel" his or her body.

6.    If your child either over exercises in isolation or is resistant to all exercise, take a group approach. Encourage your child to participate in exercise activities with others (i.e. a family hike, joining a team sport, etc.).


Not sure if your child is having these issues? Contact us for more information about our Comprehensive Eating Disorder Assessment. Call to speak with a doctor for more information or email tlepage@lepageassociates.com.



Is Bariatric Surgery Right For You?


The prevalence of obesity has reached epidemic proportions. According to the World Health Organization (WHO), obesity is the largest public health concern of the 21st century. It results in physical and psychosocial co-morbidities, as well as poor quality of life. Heart disease and stroke, diabetes, sleep disorders such as sleep apnea, and cancer are just some of the medical conditions that are the associated with obesity. It is also associated with debilitating psychological symptoms such as depression, as well as impaired health-related quality of life. This is especially true for the morbidly obese, who face an added challenge of stigmatization and discrimination. Since obesity is caused by a complex interplay of genetic, social, cultural, psychological, and environmental factors, it continues to be a challenging public health concern to overcome.


An individual who is 100 pounds overweight or has a BMI greater than or equal to 40 kg/m2   is considered morbidly obese. Although traditional treatment options, such as diet, exercise, and behavior modification are necessary to reach optimal weight, research has shown that this alone is relatively ineffective for the morbidly obese. For many people struggling with morbid obesity, weight loss eventually leads to weight gain, frustration, and disappointment. With these extreme cases, bariatric surgery is the treatment of choice and is evident with the demand increasing dramatically in the past few years. The most common types of bariatric surgery are: gastric bypass, adjustable gastric band, vertical banded gastroplasty, and gastric sleeve surgery. These options should be discussed thoroughly with a bariatric surgery specialist.


Since improved quality of life and enhanced psychosocial functioning are important goals of bariatric surgery, success following surgery should not only include weight loss, but also improvements in eating behavior, psychosocial variables and quality of life. Therefore, it is important for individuals to learn to adjust their eating behavior and lifestyle both before and after surgery in order to maintain long-term weight loss. There is a chance of not losing any weight, gaining weight, or having other adverse reactions if lifelong compliance with behavioral changes is compromised.


Here are the lifestyle changes that have been correlated with successful outcomes after having bariatric surgery:


  1. Adjustment of eating patterns.
  2. Adherence to a strict nutritional and exercise regimen. 
  3. Acquiring adequate coping skills to manage emotional eating, and difficult emotions such as anxiety and depression.  
  4. Acquiring adequate social support both at home and in the community (e.g., joining a bariatric support group or other weight-management group).

Psychologists have found that compliance with the above lifestyle changes is correlated to psychosocial factors, personality, and behavioral factors. Since success is dependent on these changes, psychologists play a key role during all stages of bariatric surgery including assessment, treatment, and maintenance. During the assessment phase, psychologists are able to provide both the client and other members of the multidisciplinary team valid psychosocial and behavioral predictors of success after bariatric surgery.


What should you expect a psychologist to focus on during the pre-surgery or assessment phase?


  1. Weight history 
  2. Eating behavior
  3. Psychosocial and psychiatric problems
  4. Expectations of bariatric surgery
  5. Influence of weight on mood and psychological functioning 
  6. Motivation for weight reduction and undergoing bariatric surgery 
  7. Attitude of the social environment towards the persons weight and desire for bariatric surgery
  8. Dieting history 

Assessing these areas allows practitioners to effectively target risk factors that the client can work on with a psychologist, nutritionist, and/or exercise specialist in order to maximize success post-surgery. Since maladaptive coping skills such as emotional eating do not change simply through surgery, psychologists continue to be an integral part of care post-surgery. Through continued individual and/or group therapy, clients learn to change their relationship with food so it is no longer used as a tool to cope with difficult emotions such as fear, anger, depression and/or anxiety. Psychologists, therefore, tend to view bariatric surgery as a mechanical solution to a problem that requires further psychological and behavioral work in order for it to be a success.  


Our Health Psychologist is experienced in working with people who have chronic health conditions such as obesity. We have extensive experience conducting evaluations for patients interested in bariatric surgery, and therapy to help patients make the necessary lifestyle changes associated with positive results pre and post-surgery. For more information please call to speak with a doctor or email tlepage@lepageassociates.com