Monday, October 13, 2014

The consequences of weight bias: beyond making you feel bad.

Debra came to me frustrated about her climbing weight, now about 20 pounds out of her normal range. This is nothing unusual for me—plenty of women and many men reach this point, desperate for answers and guidance to help them take charge of their weight. Others present for help managing symptoms or medical outcomes—like high blood pressure or cholesterol or GERD that have more to do with the quality of their diet than with their weight.

Debra was an active woman in her 50s, a non-emotional eater—yes, they do exist—who felt like she was doing most things right. She ate regular meals and snacks; she had to, as she started to feel really low energy, and fuzzy headed if she didn’t. And she’d start to get the sweats, too. She had a history of very high cholesterol, and a family history of Type 2 diabetes as well. And the weight she had previously maintained, her normal weight, was nothing crazy, nor did it require heroic measures to achieve it. Her goals were quite realistic.

After reviewing Debra’s intake and activity, I made modest recommendations to ensure she was doing whatever was reasonable in terms of change. Was she still getting the workout that she thought she was, or does she need to evaluate her intensity or duration? Perhaps with better conditioning she could prevent further weight gain. Was she inadvertently influenced by the halo effect—having more of those foods she believed to be healthy, such as lean protein sources or nuts—without an awareness of just how much was enough? ( Fullness was challenging to observe, she had stated. Perhaps she needed to evaluate just how much she needed as opposed to portioning her food on autopilot, without much attention to her need or While these recommendations were helpful—and prevented further weight gain—it was clear to me that another explanation was responsible. She had many markers for polycystic ovarian syndrome (PCOS) or hyperinsulinemia, a condition where high circulating levels of insulin result in symptoms of low blood sugar (including the sweats, fuzzy headedness, irritability and immediate need for food). (For more on hyperinsulinemia

At my suggestion, she went to see an endocrinologist—an MD appropriate for evaluating such conditions. From Debra’s report she shared her sense of despair about her climbing weight and belly fat, yet the doctor began to dismiss her, like all the overweight women who presented before her, with a simplistic, patronizing “Eat less and exercise more”. Yes, judgment was decreed without even listening to how high her activity already was and how appropriate her eating has consistently been. 

But once she added the comment about the symptoms between eating—those low blood sugar-type symptoms—he got it. He finally recognized that it was unfair to put the blame on her—to simply tell her she needs to exercise more or eat less because after all, weight management is about energy balance. He put her on metformin, which addresses the underlying issue—it’s an insulin sensitizer, so it helps prevent excess levels of circulating insulin.

The outcome? Most importantly, her symptoms stopped and she felt so much better. No more shakiness in between meals, and the sweats ceased, too. And, her weight dropped about 9 pounds over the past year, in contrast to the weight climb the preceding year that felt so out of her hands.

Weight bias in reverse

Another active woman—at a normal and stable weight, recently had a physical. She’s a 51 year old who enjoys food and eats a healthy diet. By healthy, I mean rich in healthy fats, whole grains, fruits and vegetables, with a reasonable intake of desserts and chocolate and wine. She’s not vegetarian—but her intake of meat is minimal—nor gluten free, nor dairy free, nor carb free. She’s a reliable reporter.  I know, because she is me! For the first time in her/my history, my cholesterol was high! The good cholesterol was high too—likely the result of my activity (I’d attribute it to genetics except neither parent had a high HDL)—but the bad, the LDL was out of any lab’s range of acceptable. Add that to my high blood pressure and that places me at further risk.

And what did my doctor do? Nothing. Other than telling me to continue to ‘watch my diet’ and maintain my activity (about which he knew little), that is. Yet the variables that I can control are already in order. My diet and exercise aren’t going to change for better so I don’t suspect there will be any astounding improvement. Most likely, my hormone status was likely the greatest factor increasing my levels—LDL can increase 15-25% with menopause! But heart disease risk similarly increases with postmenopausal elevations in cholesterol. 

Me (in Robin's hand-me-downs) and my slim father who had type 2 DM,
high blood pressure and high cholesterol
In spite of my high cholesterol, my doctor didn’t suggest that I have it rechecked in 3 months or that I start a statin to lower the levels. He didn't explore my exercise frequency, intensity or duration. While the updated 2014 cardiac risk calculator concludes statins for cholesterol lowering aren't necessary for me, (and doesn't include weight in the assessment) he didn't plug the numbers into this risk analyzer (I did later though.) No, I did not look like a high cholesterol patient so my cardiac risk was minimized.

I share this for those of you still blaming yourself—for your health, and for your weight. That is not to say that there aren’t things you can do to take charge of your health. Physical activity in moderate levels can improve insulin sensitivity, lower cholesterol, improve blood sugar and assist in energy balance. Oh, and it certainly may help mood and sleep, too. And eating portions appropriate for your need can help everything from reflux to fatigue to your weight climbing out of your normal, healthy range. Eating more home prepped meals can give you more control of portions and meal content. Even for you non-cooks, there are plenty of easy-to-prepare, yummy dishes you can make, with practical strategies for pulling it all together. And avoiding long periods without food certainly will improve your energy level and your control of eating when you finally take the time to eat.

But if you’re already doing what’s in your hands to do, don’t let others burden you with blame. And start to advocate for the care you deserve.

When I see my new doctor, you can bet I’ll be discussing my labs and inquiring about any treatments that might lower my risk. Because truly, my high cholesterol is not my fault.

thanks for reading!

Tuesday, October 7, 2014

Doing what we can to help eating disorders.

I don't know Jean Forney, a Phd student and AED (Academy for Eating Disorders) member studying eating disorders, but she has some very interesting ideas. She recently contacted me requesting I do a blog post on her research. Better yet, I thought--you can do it! I wasn't just passing the buck, but preferred to give her the opportunity to describe her proposal. 

One step in the right direction.
Measuring hormone levels to help predict eating disorder recovery (keep reading for the full description) is not simply about determining how long your eating disorder will last. It may offer insights about biological causes of eating disorders and ultimately to treatments for bulimia, binge eating disorder and purging disorder. 

I post this to offer hope--to show what young researchers are exploring to better understand eating disorders and help the path to recovery. And to offer you an opportunity to personally support the research (see her link at the end). 

The Importance of Physiological Research to Help Eating Disorder Treatment
By K. Jean Forney, M.S.

Eating is both a biological and psychological process. Deciding what to eat, when to eat, etc. - it’s governed by both our mind and our biological make-up. In trying to understand and treat eating disorders, more and more research is focusing on physiological processes to help supplement what we know about the role of the mind and psychological factors in eating disorders.
Two hormones involved in eating come to mind: cholecystokinin (CCK) and leptin. CCK is released from the gut during digestion. It sends a signal to the brain that says “Hey, I’m full!” and leads you to stop eating. Multiple studies have found that CCK is released more slowly in individuals with bulimia nervosa, an eating disorder characterized by binge eating and purging, compared to individuals without an eating disorder. In contrast, the CCK response appears to be normal in individuals with purging disorder, an eating disorder characterized by purging in the absence of binge eating. This led the authors who conducted the study to conclude that delayed CCK response is likely related to binge eating. 
Problematically, when you look at people at one point of time, you do not know if dysregulated CCK response occurred before the eating disorder started, or if it is a consequence of the eating disorder, or a combination of the two.  It also means that we do not know if a dysregulated CCK response makes someone more likely to binge eat and keeps the eating disorder perpetuating itself over time.
The other hormone I mentioned was leptin. Leptin is a hormone secreted from fat tissue. It is sometimes called an “adipostat” because it tells the body how much fat tissue it has. When leptin levels are too low, the brain is told to eat more via a network of neurons, neurotransmitters, and other hormones, and people become more hungry. Leptin levels appear to be lower in people with bulimia nervosa and purging disorder compared to people without eating disorders, and some authors have found that leptin levels are associated with duration of illness. That is, the lower the leptin levels, the longer someone has been ill. It makes you wonder if lower leptin somehow contributes to the eating disorder lasting longer, or if having an eating disorder causes lower leptin levels.
To answer that question, you need to study people at multiple time points.
I am running a study that will see how CCK and leptin levels predict eating disorder remission over time. Multiple women with bulimia nervosa and purging disorder have already participated in studies and had their CCK and leptin levels measured through blood draws. I will be interviewing these women, on average, 10 years after they had their blood drawn. Then, we will have some information as to whether or not these disruptions influence how likely someone is to recover from their eating disorder. This is part of a larger study looking at the long-term outcome of purging disorder and comparing it to bulimia nervosa.
Why does this matter? Well, the more we know about the processes that keep eating disorders going, the better interventions we can develop. Perhaps by treating both the body and the mind, we can help people have healthier, happier lives, free from the distress and impairment that eating disorders cause.

To read more about my study or to donate to help support the study, please see my website are some of the articles I gathered this information from, for your interest:
 Keel PK, Wolfe BE, Liddle RA, De Young KP, Jimerson DC. Clinical features and physiological response to a test meal in purging disorder and bulimia nervosa. Arch Gen Psychiatry. 2007;64(9):1058-1066. PMID: 17768271 Monteleone P, Martiadis V, Colurcio B, Maj M. Leptin secretion is related to chronicity and severity of the illness in bulimia nervosa. Psychosom Med. 2002;64(6):874-879. PMID: 12461192 Jimerson DC, Wolfe BE, Carroll DP, Keel PK. Psychobiology of purging disorder: Reduction in circulating leptin levels in purging disorder in comparison with controls. Int J Eat Disord. 2010;43(7):584-588. PMCID: 2891937
Expect another post from me soon!  And please share any thoughts about Jean's research here. Your voice really matters! Lori

Saturday, September 27, 2014

Don't wait for an earthquake to shake you into action.

I was talking to a guy from San Francisco this week, and the subject turned to earthquakes. This long-time SF resident and survivor of the big quake of 1989 offered some very practical advice for me to share with my son, a San Francisco newbie, fortunately na├»ve about the seriousness of going through an earthquake. His focus was not on what to do during the crisis—although that advice is critical as well—but rather what to do before hand. How to be prepared for this challenging situation, because being prepared, as he put it, is the surest way to increase survival.

Imagine that while sitting and discussing such matters my mind moved to you, my dear readers. No, there’s no need to worry about earthquakes for most of you. Rather, the subject of preparedness as a means to ensure survival and minimize damage struck me as most fitting—whether you struggle with an eating disorder or living free of diet rules.

Have a plan, he said. In San Francisco that might mean knowing which are the secure places to hover—the solid doorways and tables to stay under. But before it strikes, he emphasized that it’s critical to have an action plan: to keep cash on hand—because you never know when you’ll need it and ATM machines simply don’t work in these situations. Have a plan for communicating with those you’re close with—because electric doorbells to apartment buildings will fail and telephone lines other than landlines will fail. A transistor radio helps you connect with the world—to reality check what’s going on outside of your own limited space. You’ll need light of course—so batteries and flashlights need to be stashed to access easily.  And of course a supply of non-perishable food as well as water. Decision-making when undernourished will surely be compromised.

Time to come out of hiding and ask for what you need.
You can guess where I’m going with this. Yes, the analogy applies to you who are metaphorically on no greater solid ground. Communication is key to survival, and planning for opening these channels is critical. Can you tell your partner you’re struggling? Can you ask for help shopping and cooking to ensure your health and nourishment? Can you simply say “I need a place to eat dinner tonight?” Can you ask them to keep the pastries off the counter when you are trying to avoid impulse eating? Can you ask for a referral to a therapist or a behaviorally oriented dietician?

Where’s your transistor radio, so to speak, your exposure to the world outside of your own thoughts? Admittedly the cultural media may not be the most fitting reality check for sane thoughts, for diet-free messages, unfortunately. What I mean is that you need exposure outside of your own disorder thoughts—someone that can ground you when you are limited inside your own space. Were you really happier when you were so much thinner? Did staying on that crazy diet truly improve your quality of life? Your mental health? Or are you using magical thinking like the way we recall old boyfriends/relationships, fantasizing about how awesome it all was--when really it was nothing of the sort? Do you think you’ll restrict just for now and then be able to simply normalize your eating? Think again!

Do you have a grounding place to run to—your doctor, therapist, dietician, perhaps even a higher level of care—if your foundation is shaking? Do you have ready to eat food for when resources are tough to come by? A reserve for when, due to all the stress, your ability to organize and think through what’s best to eat may be impaired?

Where will your light come from when the power goes out? Do you recharge with talk therapy, or maybe yoga or meditation? Do you get spiritual support or guidance from wise friends or loved ones?
You may get no warning before the quake, before the shake up to your healthy behaviors and thoughts. So have a plan. Be prepared.

What steps will you take? Please share—we can all use to hear some ideas!

Read more about slips and relapses:

Sunday, September 7, 2014

It's your mom's fault? Words and genes: what we can do about eating disorders

It's all your mother's fault.
Really, it's about lack of approval from your dad.
If you're a boy or a man, it must mean you're gay.
If you aren't underweight you certainly don't have anorexia.
As long as you're eating healthy foods, you're okay.
It's simply a choice.
Once you've had it, you'll never truly recover.
It's all about appearance and weight.
You have to be ready to recover.

True statements? Not at all. These commonly held misbeliefs about eating disorders do only harm. They minimize the complexity of eating disorders and the struggle of those suffering with anorexia, bulimia, and binge eating disorder. 

They prejudice everyone from those living with an eating disorder, to providers treating those they may or may not know have eating disorders. 

They lay guilt on parents who may be among the best supports for their kids in recovery, as evidenced by the FBT model. 

They stereotype people based on weight--as if BMI alone determines severity of eating disorders! My normal weight patients who subsist on 400 calories surely know better. As do those of my disordered obese patients who have struggled with size discrimination for most of their lives and are no less free of obsessive thoughts, patterns of severe food restriction and symptoms of starvation. Yes, weight, size and appearance mislead.

And if we wait until someone is "ready" to recover, it just might be too late. Yet just these past weeks I've heard that this was the guidance conveyed by a therapist 'treating' a patient with an eating disorder--"you've got to wait until you're ready" they were foolishly advised; no, undernourished people don't tend to make the wisest and healthiest decisions. That's right up there with the wisdom of the cardiologists who recently minimized the very serious risk of severely restricting intake; suggesting no need for worry because Sara was not actively purging (simply overexercising and restricting) or that Dan's low heart rate must just be a result of being an athlete (a starved one, that is, with a low metabolic rate).

Yes, there is work to be done.

Eating disorders need science, not stigma

Here's yet another brilliant idea from Cate Sangster (the first I'm familiar with is her suggestion for an eating disorder recovery cookbook, which we created to great acclaim--food to eat). This time, in recovery, Cate puts her social media savvy and creative thinking to great use with this ice bucket alternative to help us get answers about eating disorders. Like Cate, I support Dr. Cynthia Bulik's move to create a genetic database to better understand eating disorders, and the organization, Charlotte's Helix which was created to help make it happen. In the US, check out this link to ANGI to donate. Please check out the resources on this site as well, to arm you with correct information about eating disorders.

"Learn From Genes, Not Jeans, About Eating Disorders."
I have followed Cate's lead with my educating arm (pic on right), and encourage you all to do the same--and to donate $20 to Charlotte's Helix or ANGI or other worthy eating disorder organizations. Share your pics  on Twitter, Pinterest and Facebook, too! 

Saturday, August 9, 2014

Avoidance isn't the answer. It's time to bear hunt.

Recovery is a tricky thing. You may be making progress with your eating—whether you are working to overcome binge eating, anorexia or bulimia—but may be fooled into believing that you’ve truly normalized  your relationship with food. It may feel like you’ve largely recovered; you’ve started to include ice cream (but only when you’re out, never keeping it in the house). And your binge frequency is close to zero. And surely you who’ve been restricting deserve credit for eating more than you used to—at least of the foods you deem good for you.

But consider this:

No, avoidance isn't the answer.

  • Is it really recovery when the only way you feel in control is to fill your days with so much activity (no, not even physical activity) that you don't get to sit with your feelings? You work long hours waitressing, take on extra shifts or extend your work hours only to avoid being with yourself. You struggle to allow yourself to feel hungry—fearing you're not trustworthy to respond correctly. You equally fear fullness, that satisfying feeling of truly getting enough. Would you allow your best friend to carry on this way?
  • Is it really recovery when you stop binging, only to restrict your food intake? You stick around family or friends because you know you'd never binge in their presence, but you also struggle to eat enough when they're around—and even when they’re not. If your child see-sawed between binge eating and restricting her food intake, would you say “that's just fine”?
It doesn't have to be so scary.
  • Is it truly changing your relationship with food when your solution for managing chocolate cake—or your favorite flavor ice cream or bread or peanut butter—is to simply never have it around? You forbid yourself access—just for now, until you meet your weight goal, or maybe believing you’ll resist these for the rest of your life. Would you suggest this to your parent, or would you hope that life could be much better for them?
  • Are you really recovering when the only way to nourish yourself (yes, I know some of you struggle with this loaded expression which implies self care in its fullest sense) is by keeping everything the same, limiting your food choices to just a few "safe" foods? Or, by weighing and measuring all of your food? No, not just for now, but forever? What would you say to your partner if he or she kept to the same restricted allowance, an even number of items to be comfortably ritually consumed, day after day after day?
Time to start living again.
  • How normal is your eating if you rely on counting your calories, or your points a la weight watchers? Or if you can't release yourself from exercising when your intake exceeds your ideal or your self-prescribed amount?

Can you truly recover? Absolutely!

Full recovery requires feeling—not avoidance of hunger and fullness. Detaching yourself from these physical sensations, like avoidance of all feelings—sadness, disappointment, fear, hopelessness—only prolongs your suffering (while admittedly for a moment it seems like the only way to get through). Avoiding feeling by numbing out with your eating or your not eating, serves a purpose. But let’s not forget that you lose out on life’s positive emotions and experiences, too.

It requires “Going on a bear hunt” so to speak—a reference to Rosen and Oxenbury’s children’s book I loved to read when my kids were very young.

"We're going to catch a big one. / What a beautiful day! / We're not scared. / Oh-oh! Grass! / Long, wavy grass. / We can't go over it. / We can't go under it. / Oh, no! / We've got to go through it!" The family skids down a grassy slope, swishes across a river, sludges through mud and, of course, finally sees the bear…”

It takes trudging through all the uncomfortable challenges—with support, of course—in order to get past your fears. Like the very young kids, you might (at first) run away when you face the bear. But with some work (perhaps there needs to be a part 2 to this classic), you’ll be embracing it and feeling all the better for it.

There’s more to life than yearning for foods you enjoy yet avoid, or regretting the little you did eat. Or struggling after a binge—an inevitable consequence of days, weeks or a lifetime of rigid diet rules, of avoiding eating enough.

You deserve better. Really you do.  I don’t mean to minimize any progress you’ve made. I simply want to urge caution to be on guard for those sneaky eating disordered thoughts and actions. So please consider reaching out to take the next step to push through—to change your thoughts, your feelings and your eating. Push through the tall grasses and the mud. And conquer the bear.

Oh, and please share your thoughts with us!