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When the Eating Disorder Client is Suicidal

When the Eating Disorder Client Is Suicidal

By Nicole Siegfried, Ph.D, CEDSnicole siegfried picture

Trigger warning/Stress warning: Triggers can be unique, inconsistent and unpredictable. Content in this article may be “triggering.” Content warning: self-harm, suicide
The information contained in this website is for general information purposes only. In no event is Gurze/Salucore liable for any loss or damage, including without limitations, indirect or direct or consequential loss or damage, or any loss or damage whatsoever arising from the use of this website. Use of the information posted is at your own risk.

Eating disorders are associated with extremely elevated mortality rates (Chesney, Goodwin, & Fazel, 2014). Although many of these deaths are related to medical complications from the disorder (e.g., arrhythmia, stroke), a significant percentage are due to suicide (Arcelus, Mitchell, Wales, & Nielsen, 2011; Crisp, Callender, Halek, & Hsu, 1992; Fedorowicz et al., 2007; Harris & Barraclough, 1997). In fact, individuals with anorexia are 31 times more likely to make a fatal suicide attempt than the general population (Arcelus et al., 2011; Chesney, et al., 2014; Preti, Rocchi, Sisti, Camboni, & Miotto, 2011), and individuals with bulimia nervosa are seven and a half times more likely to die by suicide than the general population (Arcelus et al., 2011; Chesney et al., 2014; Preti et al., 2011). Additionally, rates of death by suicide among individuals with eating disorders are elevated compared to other mental health disorders, including depression, bipolar disorder, and schizophrenia (Chesney et al., 2014).

Conceptualizing Suicide in Eating Disorders

An understanding of suicidality and how it develops in individuals with eating disorders is necessary for clinicians to effectively treat clients with eating disorders. Many clinicians have misconceptions about suicide in eating disorders and mistakenly attribute the high suicide rate to clients’ fragility and compromised medical condition. Other providers have the misconception that individuals with eating disorders develop eating disorders as a death wish or as a way to slowly kill themselves. Clinicians should have a clear understanding of the myths and facts related to suicide and eating disorders to be able to provide effective assessment and intervention (see Table 1). Additionally, clinicians who treat eating disorders need to have a clear understanding of the suicidal mind and a framework for conceptualization of suicidality in eating disorders.

Suicide as Psychache

According to Shneidman (1996), “psychache,” which is defined as an overwhelming psychological pain, is at the root of suicidality. This psychological pain can best be understood as an amalgamation of fear, shame, anxiety, rejection, guilt, sadness, burdensomeness, disconnection, hopelessness, and other negative emotions. The profound pain associated with psychache results in an inability to effectively problem-solve, seek alternate solutions, or imagine a future. Psychache is also associated with difficulty eating, sleeping, working, and soliciting help from others (Schneidman, 1993). Psychache is so debilitating that the person experiencing it would rather endure the physical pain of death to relieve the psychological pain of psychache.

Interpersonal Psychological Theory of Suicide

Expounding on Schneidman’s theory of psychache, Joiner (2005) proposed The Interpersonal Psychological Theory of Suicide (IPTS). According to Joiner’s theory, psychological pain results from a combination of perceived burdensomeness and thwarted belongingness, which result in suicidal desire. Suicidal capability is the result of an acquired sense of fearlessness toward death and tolerance of physical pain. The intersection of suicidal desire (burdensomeness, thwarted belongingness) and suicidal capability (fearlessness toward death and pain tolerance) creates a perfect storm that can lead to a fatal outcome (see Figure 1).

The IPTS model provides a compelling framework for understanding suicide in eating disorders, and has received preliminary empirical support in various studies (Crow et al., 2008; Selby et al., 2010; Smith et al., 2013). Individuals with eating disorders may develop perceived burdensomeness based on their perception of the impact of their disorder on their families. Carrying the psychological pain associated with psychache can also create a level of burdensomeness for individuals with eating disorders. Finally, clients with eating disorders often report burdensomeness based on the demands of treatment and recovery. For example, gaining weight, working through trauma, or experiencing emotion can create a level of burdensomeness that feels intolerable. Individuals with eating disorders also report thwarted belongingness. They report feeling isolated from others, detached from their identities, and disconnected in mind, body and soul. Capacity for suicide in eating disorders develops through the use of eating disorder behaviors. Based on the lethality and violence associated with vomiting, severe restriction, hard exercise, and/or diuretic/laxative use, eating disorder clients may develop a fearlessness of death while heightening their pain tolerance. Other violent behaviors, such as self-harm and substance abuse, which are common in eating disorders, may further amplify the capacity for suicide. The usefulness of the IPTS model in conceptualizing suicidality in eating disorders may also be helpful in guiding assessment and intervention.

Suicide Risk Assessment

In general, mental health providers are poorly trained to assess suicide risk. The majority of graduate programs provide less than four hours of formalized training in suicide assessment (Schmitz et al., 2012), and a large number of clinicians conduct inadequate suicide assessment or fail to detect suicidal ideation in their clients (Bongar, Maris, Berman, & Litman, 1998; Simon, 2002). Based on the high rate of suicide in eating disorders, lack of training and incompetence in suicide assessment is particularly concerning. To date there are no known investigations of competence in suicide risk assessment for eating disorder clinicians, but it seems reasonable to assume that there is a similar lack of training to that of mental health providers. Based on the high rate of suicide in clients with eating disorders, it is recommended that clinicians treating eating disorders receive specialized training in suicide assessment and intervention.

Suicide Risk Assessment: What Not to Do.

Self-Report Checklists. Despite the frequent use of self-report suicide risk checklists in clinical settings, they have not been found to demonstrate the comprehensiveness or accuracy to adequately predict suicide risk. As such, they are not recommended to be used in isolation when assessing suicide risk in eating disorder clients. In addition to a self-report checklist, it is necessary to conduct a more comprehensive and integrative clinical assessment with each client to accurately determine suicidal risk.

No-Suicide Contracts. Along similar lines, it is also fairly common for clinicians to routinely utilize no-suicide contracts (Miller, Jacobs, & Gutheil, 1998), which require clients to agree that they will not engage in suicidal behavior. To date, there is no evidence that no-suicide contracts actually prevent suicidal behavior (Joiner, Van Orden, Witte, & Rudd, 2009). In fact, in one study up to 50% of individuals who had died by suicide had signed a no-suicide contract (Kroll, 2000). Additionally, there has been no legal precedent in which a no-suicide contract has protected clinicians in litigation (Simon, 1992). Furthermore, there is evidence that the use of no-suicide contracts creates a false sense of security for clinicians, and interferes with their ability to conduct a comprehensive and accurate suicide risk assessment (Simon, 2002). Based on these findings, other methods of assessment and intervention are recommended.

Suicide Risk Assessment: What to Do.

Comprehensive Suicide Assessment. Several methods of comprehensive suicide risk assessment have been proposed (See Joiner et al., 2009 for a full discussion of these measures). In this article one method of evidence-based risk-level assessment and intervention is presented that may be helpful for clinicians treating eating disorder clients. The Suicide Risk Decision Tree (Joiner, Walker, Rudd, & Jobes, 1999) assesses three main indicators of suicide risk (i.e., past suicidal behavior, current suicidal desire/ideation, and current resolved plans and preparations), as well as additional risk and protective factors. The Suicide Risk Decision Tree (see Figure 2) is a semi-structured integrated interview, which requires appropriate clinical training to appropriately and accurately determine suicidal risk. The risk assessment framework assesses for past suicidal behavior, which has been identified as the most significant predictor of future suicide attempts (e.g., Putnins, 2005) and death by suicide (e.g., Brown, Beck, Steer, & Grisham, 2000). The interview also assesses Suicidal Desire and Ideation (i.e., relatively vague thoughts about wanting to be dead) and Resolved Plans and Preparations (i.e., more specific thoughts about and planning for a suicide attempt). The endorsement of additional risk factors (e.g., stressors, feelings of hopelessness) may increase risk. Protective factors (e.g., increased social support) are also assessed, and may buffer risk for suicide. The information obtained in the clinical interview is utilized to categorize suicidal risk into low, moderate, and high risk, using the flow chart from Figure 3.

Risk-Level Interventions. The Suicide Risk Assessment Decision Tree provides a fairly straightforward method to assess suicide risk and offers a framework to guide interventions based on risk level (see Figure 4). For clients who are at low or mild risk, it is recommended that the clinician help the client create a coping card or a de-escalation plan to address suicidality that may arise during the course of treatment. A common format includes: “If I should become suicidal, these are the actions I will take and the coping skills I will utilize.”

For individuals who are at moderate risk, the use of a safety plan is recommended. A safety plan (see Figure 5) is typically more detailed and specific than a coping card or de-escalation plan and differs from a no-suicide contract in that it focuses on what the client will do as opposed to what the client will not do. The traditional safety plan can be enhanced by including reduction of access to means. Research shows that reducing access to means is one of the most effective interventions for preventing suicide (Sarchiapone, Mandelli, Iosue, Andrisano, & Roy, 2011). Including reminders of reasons for living can also enrich the safety plan. As a function of the constricted thinking, clients who are suicidal often have difficulty accessing reasons for living. Research has shown that recalling reasons for living during a suicidal crisis can decrease suicide risk (Rudd et al., 2015).

For individuals at high suicide risk, the same methods of safety planning and means reduction that are used for moderate suicide risk are recommended. For individuals at high risk, an assessment of imminent harm is necessary. For those individuals at imminent risk, psychiatric hospitalization may be necessary to provide safety. It is recommended that clinicians seek consultation when making decisions for moderate and high risk clients and that they document reasoning behind which methods of intervention were chosen and not chosen.


Based on the high rate of suicide in eating disorders, it is imperative that eating disorder clinicians have a good understanding of suicide in this population and demonstrate competence in assessing and treating suicidality. Evidence-based suicide risk level determination can guide eating disorder clinicians to appropriately intervene with suicidal clients to provide effective treatment and ultimately save lives.

Table 1. From: Joiner, T. (2010). Myths About Suicide. Cambridge, MA: Harvard University.

Copyright 2010 by the American Psychological Association (APA). Reprinted under APA’s fair use policy.


EDs are really a slow suicide
EDs are characterized by a desire for thinness and to not feel rather than a desire for death.
Individuals with AN are less likely to choose violent methods of suicide because these individuals tend to be harm avoidant
Although individuals with AN demonstrate harm avoidant tendencies, they have become habituated to bodily damage which overrides harm avoidant nature.
Individuals with ED's are more likely to die by suicide because they are medically compromised.
Individuals with EDs are more likely to die by suicide attempt because they utilize more lethal means in an attempt.
Individuals with EDs tend to attempt suicide because they have more selfish traits than individuals with other disorders.
Individuals with or without EDs who attempt suicide tend to do so to relieve their perceived burden on others, rather than as a selfish act.
Individuals with EDs are more impulsive and therefore more likely to make an impulsive decision to die by suicide.
Most suicides are the result of long planning and deliberation - with or without an ED.
The majority of people with or without EDs who have thoughts of suicide will attempt suicide at some point.
The majority of individuals with suicidal thoughts do not attempt or die by suicide.
There is an increase of suicides around the winter holidays.
The most common time of the year for suicides is during the spring.
Suicide attempts are just cries for help or to get attention.
Individuals who attempt suicide are experiencing true psychological pain, and are unable to articulate their pain and ask for help.


Screen Shot 2015-08-28 at 12.16.29 PM

Figure 2. Decision Tree Interview. Adapted From The Interpersonal Theory of Suicide: Guidance for Working with Suicidal Clients, by T. E. Joiner, Jr., K. A. Van Orden, T. K. Witte, and M. D. Rudd, 2009, p. 72. Copyright 2009 by the American Psychological Association (APA). Reprinted under APA’s fair use policy.

Trigger warning/Stress warning: Triggers can be unique, inconsistent and unpredictable. Content in this article may be “triggering.” Content warning: self-harm, suicide
The information contained in this website is for general information purposes only. In no event is Gurze/Salucore liable for any loss or damage, including without limitations, indirect or direct or consequential loss or damage, or any loss or damage whatsoever arising from the use of this website. Use of the information posted is at your own risk.
To be used by a trained clinician only –

Assess History of Suicidal Behavior:

  1. Past suicidal behavior: Have you attempted suicide in the past? How many times? Methods used? What happened (e.g., went to hospital?).
  2. Do you have a history of non-suicidal self-injury? (e.g., burning, cutting, etc.)

Assess Suicidal Desire and Ideation:

  1. Have you been having thoughts or images of suicide?
  2. Do you ever think about wanting to be dead?
  3. Frequency of ideation: How often do you think about suicide?
  4. What reasons do you have for dying? What reasons do you have to continue living?

Assess Resolved Plans and Preparations:

  1. Duration [look for pre-occupation]: When you have these thoughts, how long do they last?
  2. Intensity: How strong is your intent to kill yourself? (0 = not intense at all, 10 = very intense)
  3. Specified plan [look for vividness, detail]: Do you have a plan for how you would kill yourself?
  4. Means and opportunity: Do you have [the pills, a gun, etc.]? Do you think you’ll have an opportunity to do this?
  5. Have you made preparations for a suicide attempt? [e.g., buying pills]
  6. Do you know when you expect to use your plan?
  7. Courage & competence: How scared do you feel about making an attempt? How courageous do you feel about making an attempt? How able do you feel to make an attempt?

Assess “other significant findings”:

  1. Precipitant stressors: Has anything especially stressful happened to you recently?
  2. Hopelessness: Do you feel hopeless?
  3. Impulsivity: When you’re feeling badly, how do you cope? Sometimes when people feel badly, they do impulsive things to feel better. Has this ever happened to you? [e.g., drinking alcohol, running away, binge eating]
  4. Has anyone in your family made a suicide attempt or died by suicide? Relationship to you? Thoughts and feelings about this?
  5. Presence of psychopathology (rated by interviewer)
  6. Thwarted belongingness: Do you feel connected to other people? Do you live alone? Do you have someone you can call when you’re feeling badly? [are supportive relationships completely absent?]
  7. Perceived burdensomeness: Sometimes people think: “The people in my life would be better off if I were gone.” Do you think that? In what ways to you feel like you contribute meaningfully to those around you? (e.g., at work, at home, in the community)

Protective Factors:

  1. Adequate social support (use responses to item 6 (assess “other significant findings”) to assess this)
  2. Responsibility to others (use responses to item 7 (assess “other significant findings”) to assess this)
  3. Good problem-solving ability: When you are experiencing distress, what do you do to resolve it? When you encounter something difficult, do you sometimes feel like you have no idea what to do to get through it?
  4. Cultural and religious beliefs against suicide

Figure 3. Suicide Risk Assessment Decision Tree. Adapted from “Scientizing and Routinizing the Assessment of Suicidality in Outpatient Practice,” by T. E. Joiner Jr., R. L. Walker, M. D. Rudd, & D. A. Jobes, 1999. Professional Psychology: Research and Practice, 30, p. 451. Copyright 1999 by the American Psychological Association. Reprinted under APA’s fair use policy.

Screen Shot 2015-08-28 at 12.18.32 PM

Figure 4. Interventions for each level of suicide risk. Adapted From The Interpersonal Theory of Suicide: Guidance for Working with Suicidal Clients, by T. E. Joiner, Jr., K. A. Van Orden, T. K. Witte, and M. D. Rudd, 2009, p. 106. Copyright 2009 by the American Psychological Association (APA). Reprinted under APA’s fair use policy.

Risk Category (circle one and check off each action taken):

Low Risk (actions taken)

  • Create a coping card with the client that includes a variant of the following, “In the event that you begin to develop suicidal feelings (or if your existing feelings become more intense), here’s what I want you to do:”
  • List at least three pleasant activities that a client could realistically do when feeling distressed (e.g., work on crossword puzzles, listen to soothing music)
  • List two or three people from the client’s support network that could be called (e.g., mother, friend)
  • List emergency numbers (including that for the National Suicide Prevention Lifeline; 1-800-273-TALK and 911)
  • Continue to regularly monitor suicide risk
  • Document all activities in progress notes

Moderate Risk (actions taken)

  • Consult with a supervisor if you are a trainee
  • Create a coping card (see above)
  • Consider midweek phone check-ins to assess suicide risk more frequently
  • Inform about existence of adjunctive treatments (e.g., medication)
  • Increase social support:
  • o   Encourage client to seek support from friends and family
  • o   Plan with client to have someone check in on him or her regularly
  • o   Ask client’s permission for you to contact the person who will be checking in
  • Attempt to remove access to lethal means (e.g., firearms, pills, etc.)
  • Ask for permission to speak with an informant (e.g., family member, romantic partner), with the appropriate release
  • Continue to regularly monitor suicide risk
  • Document all activities in progress notes                       

High Risk (actions taken)

  • Consult with a supervisor if you are a trainee or with a colleague if you are not a trainee
  • Consider emergency mental health options (e.g., hospitalization)
  • Client should be accompanied and monitored at all times
  • If hospitalization is not warranted, use suggestions from the Moderate Risk category
  • Document all activities in progress notes (including documentation that hospitalization was at least considered)

Figure 5. Sample Safety Plan. Adapted from Bartlett, M. & Siegfried, N. (April, 2012). Bridging the treatment of eating disorders and suicidality. Workshop presented at the Annual Conference of the American Association of Suicidology in Baltimore, Maryland.

Safety Plan

  • When I start to feel emotionally distressed or feel like I want to hurt myself or kill myself, five things that I can do to soothe myself and manage my feelings and/or urges are:


  • When I start to feel like I might act on an unsafe behavior (e.g., self-harm, suicidal behavior), five things I can do to prevent the behavior are:


1. Create a safe environment:




2. Remind myself of at least 2 reasons for living and recovering:



3. ______________________________________________________________________

4. ______________________________________________________________________

5. ______________________________________________________________________

  • I agree that after I have followed through on the above coping skills, if things are still difficult for me and I believe I might hurt myself, I will do the following:

1. If I am at the facility, I will inform a staff member, who will assist me in being safe.

2. If I am away from the facility, I will

Call the National Helpline: 1-800-273-TALK

Or Contact the local police (phone number): ________________________________

Or Go to the nearest emergency room ____________________________________

This article was adapted from a previous article: Bartlett, M. L., Siegfried, N., & Witte, T.K.  (2013).  Best practice clinical interventions for working with suicidal adults.  Alabama Counseling Association Journal Special Edition Suicide Prevention, Intervention, and Postvention with Youth, Adults, and the Elderly, 38, 65-79.  

About the author –

Dr. Nicole Siegfried is a Certified Eating Disorder Specialist (CEDS) and a licensed clinical psychologist. She is the Clinical Director of Castlewood at The Highlands Treatment Center for Eating Disorders in Birmingham, AL. She previously served as an Associate Professor of Psychology at Samford University and is currently Adjunct Associate Professor of Psychology at University of Alabama at Birmingham. She is an international speaker and has published research, magazine articles, and book chapters in the field of eating disorders. Presently, Dr. Siegfried is an investigator on a research study with Dr. Thomas Joiner examining resilience and suicidality in eating disorders. She is president of the Alabama Regional Chapter of IAEDP, which is in the formation stages. She is a member of the Academy of Eating Disorders (AED) and Co-Chair of the Eating Disorders and Suicide Prevention AED Special Interest Group.

References –

Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders: a meta-analysis of 36 studies. Archives of General Psychiatry, 68(7), 724.

Bartlett, M. &Siegfried, N. (April, 2012). Bridging the treatment of eating disorders and suicidality. Workshop presented at the Annual Conference of the American Association of Suicidology in Baltimore, Maryland.

Bongar B, Maris RW, Berman AL, & Litman, R (1992). Standards of care and the suicidal patient. Suicide Life Threat Behav. 22(4):453-78.

Brown, G., Beck, A. T., Steer, R., & Grisham, J. (2000). Risk factors for suicide in psychiatric outpatients: A 20-year prospective study. Journal of Consulting and Clinical Psychology, 68, 371-377.

Chesney, E., Goodwin, G. M., & Fazel, S. (2014). Risks of all‐cause and suicide mortality in mental disorders: A meta‐review. World Psychiatry, 13(2), 153-160.

Crisp, A. H., Callender, J. S., Halek, C., & Hsu, L. (1992). Long-term mortality in anorexia nervosa. A 20-year follow-up of the St George’s and Aberdeen cohorts. The British Journal of Psychiatry, 161(1), 104-107.

Crow, S., Eisenberg, M. E., Story, M., & Neumark-Sztainer, D. (2008). Are body dissatisfaction, eating disturbance, and body mass index predictors of suicidal behavior in adolescents? A longitudinal study. Journal of Consulting and Clinical Psychology, 76(5), 887.

Harris, E. C., & Barraclough, B. (1997). Suicide as an outcome for mental disorders. A meta-analysis. The British Journal of Psychiatry, 170(3), 205-228.

Joiner, T. E. (2005). Why people die by suicide. Cambridge, MA: First Harvard University Press.

Joiner, T.E. (2010). Myths about suicide. Cambridge, MA: Harvard University.

Joiner, T. E., Van Orden, K. A., Witte, T. K., & Rudd, M. D. (2009). The Interpersonal Theory of Suicide: Guidance for Working with Suicidal Clients. Washington, D.C.: American Psychological Association.

Joiner, T. E., Walker, R. L., Rudd, M. D., & Jobes, D. A. (1999). Scientizing and routinizing the assessment of suicidality in outpatient practice. Professional Psychology: Research and Practice, 30, 447-453.

Kroll, J. (2000). Use of no-suicide contracts by psychiatrists in Minnesota. The American Journal of Psychiatry, 157, 1684-1686.

Miller, M. C., Jacobs, D. G., & Gutheil, T. G. (1998). Talisman or taboo: The controversy of the suicide prevention contract. Harvard Review of Psychiatry, 6, 78-87.

Preti, A., Rocchi, M., Sisti, D., Camboni, M., & Miotto, P. (2011). A comprehensive meta‐analysis of the risk of suicide in eating disorders. Acta Psychiatrica Scandinavica, 124(1), 6-17.

Putnins, A. L. (2005). Correlates and predictors of self-reported suicide attempts among incarcerated youths. International Journal of Offender Therapy and Comparative Criminology, 49, 143-157.

Rudd, D., Bryan, C., Wertenberger, E., Peterson, A., Young-McCaughan, S., Mintz, J., Williams, S., … Bruce, T. (2015). Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: Results of a randomized clinical trial with 2-year follow-up. American Journal of Psychiatry, 172(5), 441-449.

Sarchiapone, M., Mandelli, L., Iosue, M., Andrisano, C., & Roy, A. (2011). Controlling access to suicide means. International Journal of Environmental Research and Public Health, 8(12), 4550–4562.

Selby, E. A., Smith, A. R., Bulik, C. M., Olmsted, M. P., Thornton, L., McFarlane, T. L., . . . Fichter, M. M. (2010). Habitual starvation and provocative behaviors: Two potential routes to extreme suicidal behavior in anorexia nervosa. Behaviour Research and Therapy, 48(7), 634-645.

Shneidman, E. S. (1993). Suicide as Psychache: A clinical approach to self-destructive behavior. Northvale, NJ: Jason Aronson.

Shneidman, E. S. (1996). The suicidal mind. New York: Oxford University Press.

Simon, R. I. (1992). Clinical risk management of suicidal patients: Assessing the unpredictable. In R. I. Simon (Ed.), American Psychiatric Press Review of Clinical Psychiatry and the Law (Vol. 3, pp. 3-63). Washington, DC: American Psychiatric Press.

Simon, R. I. (2002). Suicide risk assessment: What is the standard of care? The Journal of the American Academy of Psychiatry and the Law, 30, 340-344.

Smith, A. R., Fink, E. L., Anestis, M. D., Ribeiro, J. D., Gordon, K. H., Davis, H., . . . Klein, M. H. (2013). Exercise caution: Over-exercise is associated with suicidality among individuals with disordered eating. Psychiatry Research, 206(2), 246-255.



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