Tuesday, August 11, 2015

FB and your diet, weight, fitness & happiness: A cautionary post about comparing.

Everyone is so happy. And doing so well, always having a great time. They’re all eating amazing food and managing their weight. They all look so healthy, too. And their kids are always smiling—they have the perfect families. Everyone else is so good at exercising—Map My Ride/Run and other apps prove they’re doing so much better than you running and cycling and walking. Yes, by comparison you hardly rate.
Hardly his happiest or his best mug shot.
Posted with permission.

Or so it seems.

It was quite timely that my patient whom I’ll call Beth, described her frustration having spent too many hours on Facebook. (Imagine that. Spending too much time on social media.)  She saw far too many ‘friends’’ photos displaying beach-bound bodies with a confidence she doesn’t possess. Like those ‘before and afters’ from diet ads from Diet Center and Weight Watchers (where the print too small to read confesses that these images are of rarely occurring weight loss that normal people don’t usually experience nor maintain in the real world) they showed what everyone else was capable of—except for her. These photos of Beth’s friends and acquaintance were beautiful—looking slimmer, happier and more fit than her for sure. 

Or so it seemed.

These pictures of friends struggling
 hardly get seen.
Ok. Raise your hands if you post pictures of yourself that you'd rather destroy. Right. We only post our best shots, the ones that get the ‘likes’, right? And we surely don’t see people throughout the day, at all times, when they may be looking their worst—like we see ourselves. No early morning “I-just-rolled-out-of-bed” shots posted on FB.  And did you know that some ‘friends’ even use apps which photoshop their pictures, like they do in magazines with airbrushing? Yes, it’s even possible that some pictures you’re thinking are real have been touched up. 

Comparison is a tricky business. You only see a small slice of a person’s life, of what’s really going on. The rest, no doubt, is projection. They ‘seem’ happy, or healthy, or content. But maybe it’s just how it appears. Their exercise level may be awesome, or excessive or a rare event advertised to their Facebook friends.

No, these imperfections don't make
it to FB.
Your friend who’s lost all that weight may have cancer, or may be struggling with anxiety and depression, causing her to feel anything but happy. Or fit. Or relaxed. The bikini clad acquaintance may be so preoccupied with what she believes she can and can’t eat that she hardly enjoys herself at the beach, or when she dines out, or even when at home deciding what she could possible have for lunch.

Yet another recent study showed that using social media can have a negative impact on our eating behaviors including binging, purging and using diet-pills. “Both online physical appearance comparison and online fat talk were associated with greater disordered eating” the study by Dr. Bulik and colleagues showed. Without the comparing, however, greater Facebook use was associated with decreased disordered eating behavior. So it’s all how you use it. "Comparison is the thief of joy"--I can't agree more with this quote attributed to Theodore Roosevelt.

Looking neither happy, nor energized.
I was actually quite miserable here.
Maybe it’s time to challenge your Facebook and social media friends. Are they capable of posting a picture where they don’t look so awesome? Can they post the ride or run where their speed was less than impressive?  I doubt that most can bring themselves to do so—but wouldn’t that change things?

I’d love to hear what you think. So please leave a comment! And thanks for reading.

Saturday, July 18, 2015

The very low sugar, low fat healthy diet—an oxymoron.

Kristen knew to avoid fats—except for those in nuts (which she included in very limited amounts) and certainly those in dairy and oils. Fats are bad. Period. She loves fat free yogurts, but those she omits because of the sugar. Same with milk, which she truly used to enjoy. Now she uses fortified water aka lite almond milk. Seasonal fruits, even the organic stuff—completely stricken from her diet, you know, because of the sugar.  Whole grains—well those have those god-awful carbs so those are out too. Yup, that leaves… lean poultry and fish and non starchy vegetables.

No wonder meal planning is a challenge.

No wonder she struggles to not binge following a day of deprivation.

No wonder her energy level is low, and her thoughts are preoccupied with food and eating.

Why can’t I decide what to eat?

If you're like Kristen, you get so over-focused on what you shouldn't eat that you're challenged to figure out what to eat.  Your endless food rules about nutrition, weight and health leave few foods to eat—and enjoy. 
I've lost count of how many patients came into my office these last weeks, stating: "I have no idea what to eat anymore. I just can't decide." These are patients of all sizes and conditions—patients with anorexia, and those with binge eating disorder and bulimia; and those struggling with their climbing weight and obesity in spite of their attempts to eat healthy. And they’re all ruled by unnecessary food rules.

Wrong, wrong, wrong about fats!

Like Kristen you too may be fat phobic, in spite of the updated newest guidelines for Americans 2015, which have removed the notion that total fat should be avoided. Got that? There is no evidence to support a recommendation that total fat should be restricted—neither for weight management nor for health and disease prevention. 
Really? How can this be?
At the 2015 Scientific Sessions of the American Diabetes Association (ADA) there was a wealth of research showing that diets rich in fats from plants sources—with nutrients like mono unsaturated fats (think avocado, peanuts and olive oil)—and in omega 3s (think salmon, sword and tuna in addition to walnuts and flax) help reduce abdominal fat distribution which is the greater health concern than obesity.

And, wrong about carbs and weight gain!

Also at the ADA, extensive research was presented concluding that macronutrients—the protein, fat and carbohydrate balance of your diet—ultimately have no impact on your weight. That's right. Numerous large studies including a well-done Harvard study confirm this.
I know, I know, it’s hard to believe when you’ve already been sucked into the misinformation of carb and sugar toxic diets and fat phobia.

You’ve lost sight of the bigger picture. In spite of eating a diet full of healthy foods including protein sources, fruits and vegetables, grains and fats—your calorie intake can become reduced to the point of providing inadequate calories for your day to day need. You get fuzzy headed, feel fatigued and decision-making about food becomes challenging. Rules and restrictions consume you, so you're at a loss to figure out what you can eat. I mean if you know you can’t eat gluten or that carbs are toxic or fats will make you fat and sugar is poison than what's left? How can you choose what to eat when there's so little that allowed?

Remember when you used to simply eat?

Move from micromanaging your foods.

How can you loosen the reins? Start to shift your thinking from micromanaging your diet. Rather than hyper focusing on each individual food item, on every nutrient or component of your intake, consider the bigger picture.

Consider OJ.

I walk through the supermarket noting the orange juice selection. Remember orange juice, the juice of oranges naturally high in vitamin C (and lesser known for its high potassium and folic acid content)? Only now it’s available calcium fortified. And get it with pulp—it’ll make you think you’re getting more fiber, when in truth there’s no difference. Add omega 3s while you’re at it—just get it with fish oils (quite a disgusting thought, personally). My point? Why are we thinking that one food has to be everything to our diet? Can't oranges or orange juice just provide us with the nutrients it's known for?

Must our pasta be whole wheat and protein fortified or be banned from our diet? What if you started with white pasta—yup, no fiber, all carbs, delicious pasta? You don't need to have the whole 16 oz. of it. By itself it's hardly a balanced meal. But surely you can find a solution to that, right?
Yes, you can add vegetables—for vitamins, for volume and texture, for fiber and satiety. Feel the need for protein at that meal? Add a glass of milk, some cheese, some shrimp or chicken or smoked salmon.  See where I’m going? 

Maybe think even bigger picture. Perhaps some meals are higher carbohydrate, but your protein is met from other meals or snacks?  Maybe you had a Greek yogurt high in protein or some nuts, for instance.

It's time to aim for balanced meals and a balanced day of eating, rather than hyper focusing on some 'perfect', ideal foods and eating style. Imagine even including a baked good simply because you enjoy it, as a snack when you’re hungry—contributing to your energy needs for the day, in addition to the wholesome foods you strive to limit yourself to.

Now that’s healthy eating.

Thoughts? Questions? Does this resonate for you? Are you out there reading? Please share with anyone who might needs some reality checking! Thanks!

Tuesday, June 9, 2015

Loved one on a diet? What their shakes and weight loss mean for you.

Your spouse or partner (or best friend) goes to the doctor and is told to lose weight. And they do. You're pleased for them—on some small level that is—believing perhaps that weight loss is in their best interest. Maybe you’re concerned about how sedentary they've become or about their risk with climbing blood sugars or cholesterol levels. You know how sluggish they’ve been and surely you’d care to see them feel better both physically and mentally. But mostly you're not so pleased. Sound familiar?

Whether you're recovering from an eating disorder or trying to break from the diet mentality and release yourself from diet rules it has "triggering" written all over. To quote my dear friend in recovery from an eating disorder "why is that he's allowed to diet and I can't?" "Why must I be the one in the family who models appropriate eating behaviors, while he restricts his grains and sucks down liquid supplements?"

It's simply not fair. They can do crash diets but you can't. Or shouldn't. Right?

I mean, how well are they really doing?
Not quite. If your loved one is following a fad diet, resulting in rapid (albeit short term) weight loss, be careful what you're longing for. The result is subsequent weight gain that exceeds the loss in most cases. And in the meanwhile, they’ll be dealing with increased irritability, fatigue, and preoccupation with food, eating and weight. Is this really what you want? You've been there before I'm sure. The fantasy of slimming down (through unhealthy measures) and morphing into a new and improved happier being is simply fantasy. You know better. I know you do.

But what about those loved ones that are changing their habits for better, resulting in their losing weight? They’re moving from TV watching while eating and starting to taste their food. They’ve started to portion their food, better reflecting their need for fuel. And their knee-jerk reaction to stress and perceived failure and depressed mood is no longer to reach for food. These changes I certainly support.

Consider that you too can focus on your behaviors. Are you eating mindfully? Respecting your hunger and your fullness? Including physical activity that's enjoyable and not compulsive, that supports your mood and well-being?  Yes, those are actions you too can take, providing you nourish your body adequately (and are medically stable and cleared by your health care provider.) Shopping and preplanning meals and snacks might help, too.

What would you tell a child who says that it isn’t fair that their friend gets to eat a different amount than they do? No doubt you’d acknowledge that we each need to meet our individual needs—based on height, weight, muscle mass, physical activity and genetics, for instance.

For some that might mean eating less, while for others eating more. For some that means figuring out how to move more, while for others it demands respect for your need for fueling your body to enable the privilege of movement. Some of us are more vulnerable to restrictive eating, triggering more eating disorder thoughts and behaviors. While others can exercise modest restraint—delaying seconds and shifting the balance of foods on their plate, for instance.

Perhaps it's time to communicate to help support each other.
But would I endorse a fad diet that appears to promise great outcomes—even based on the short-term results you might find alluring—for anyone? No! I would have a heart-to-heart with your loved one to explain why that approach is not constructive. Not because you feel threatened by their weight loss, but because you sincerely care about their well-being and you know where restrictive diets lead. (And for the record, the macronutrient content—whether high protein or low fat or low are high carb—has no bearing on weight loss. Really. So do set the record straight!)

Their weight loss may not seem fair. But neither is the price of restrictive eating, of feeling like you're on a diet. You've been there. You know better. It's a short term high, and a terrible drop after that.

Remember how you enjoy your freedom, your right to eat the foods you love and give you pleasure. Remember that trusting your body to eat enough enables you to think clearly and decrease preoccupation with food. Remember how bad it feels when the rebound weight gain follows the severe food restriction, the dieting that’s looking so appealing.

You're an adult and you can do what you'd like. But do you really think another diet is going to make things better? Now please go talk with your loved one.

Friday, May 29, 2015

The truth about the rumors about me.

Yes, I'm direct.
Today I heard reference to me and how I practice, shared by a patient, spoken by a therapist. "She's extreme", the therapist reportedly said, referring, no doubt to my reaction to my new patient's eating disorder behaviors and her severely restrictive intake. I bypassed the "let's just wait and see" approach after a mere couple of visits, after noting the wac-a-mole pattern to her "recovery". Stop the laxatives, increase the purging, increase the food, double the exercise. And there weren't the necessary supports at home to help implement change and ensure her safety and her progress. 

It's not the first time strong descriptives have been used about me and my management of eating disorders. I've been called  "tough" and "not easy". It's a wonder anyone would choose to come to see me. I sound so scary, no?

So let me fess up. It's all true. 

My stand against eating disorder behaviors is extreme-- extremely intolerant. Not of the patient, but of the disordered behaviors. Purging and laxative abuse and severe calorie restriction has extreme consequences. Yes, eating disorders can and will kill, regardless of BMI. And in my view, there's no other stand to take than an extreme one, a zero tolerance for allowing the eating disorder to suck away the life of you or your loved one. 

A dietitian who tells it like it is and sets limits
isn't all that bad.

That doesn't mean my recommendations are extreme, although one's eating disorder may believe otherwise. 

Being told to stop exercising, yes stop exercising, when you consume too few calories to prevent damage from exercise can feel extreme.But so is the muscle wasting that results from starvation when your body tries to produce the fuel to sustain your workout or sport. And, the consequential reduction in bone density, the osteopenia and osteoporosis and resulting fractures. And the impact on hormone production, and mood, and energy level. Yes, the impact of eating disorders is extreme. 

When indicated, I will shake things up. I'll recommend moving from rigidity around foods and nutrients, but I'll guide patients on moving forward. I'll expect patients to be medically stable and low risk before supporting exercise. And if additional support is needed, I'll direct patients to a higher level of care when necessary.

Do families and those with eating disorders really want a provider who simply says what they'd like to hear? Someone who agrees that there's no need for a higher level of care if you don't want to go? Someone who speaks words the eating disorder prefers, shares messages that keeps the anxiety low, and placates those parents in denial about the eating disorder reality--even when things aren't going well? Colluding with the eating disorder is not therapeutic support and patients and their families deserve better.  So call me tough. 

It's my hope, though, that tough isn't equated with uncompassionate or insensitive. Because if that's the rumor something has to change. As I've written before, there needs to be support and compassion, and a sense that you and your disorder are well understood to begin to trust that recovery is possible.

Yes, I'd love to hear your thoughts! Thanks for reading. See more below:

Tuesday, May 5, 2015

All about the numbers.

If you share my frustration please share this post with those that need to see it.

Dear Insurance Company,

I wish you could see what I see. I wish you could know how much work it requires to motivate an adult living with an eating disorder to trust enough to agree to enter a program.

Everything is against their entering treatment—taking time off from work if their job will even allow it, getting coverage for their kids, telling people they know when their eating disorder is often their own secret, and enduring the shame of acknowledging that they are actually struggling with this disease—the shame of feeling that they ought to be over this by now. And the shame that comes with not fitting into society’s skewed perspective of what someone with an eating disorder looks like—because even those of normal weight and BMI can live silently with an eating disorder.

Image what it’s like to then have your patient dumped from program. Sound harsh? Well that’s how it feels, both to them and to us as their providers. A mere 2 weeks in a residential program (following years living with their disorder) and they’re required to step down, told they don’t need to stay there any longer, that it will no longer be covered.  And the patient? She is not happy at all. That very reluctant patient is finally finding her voice and stating loud and clear that she desperately needs to remain there. Her ED thoughts are so loud that the controlled environment of resi is the only thing that is resulting in the positive outcomes observed at program. So she is discharged because she has done well.

The premature move to partial day program, PHP sets her up for failure. And because her behaviors return, she is again discharged. Yes, now released because she’s not doing well enough, without a plan to move her to the more appropriate higher level of care. Can you see the absurdity?

Some numbers matter

We certainly do need to look at numbers—but not necessarily the ones that insurers like you are assessing. Weight may tell less than most other measures. Believe it or not, a weight may be completely in the normal BMI range (or even high) and an individual may be struggling with an eating disorder.  This is anything but rare, I’ll tell you. And weight may change little as eating increases significantly as metabolic rate increases in patients with anorexia. Patterns of restrictive eating followed by binging and even purging may have little impact on weight, or may support weight gain. So focusing on this number is truly misdirected.

These numbers matter

How about the EDE-Q score which assesses eating behaviors and disordered thoughts? It’s a quantitative test to measure change in recovery. Pulse, particularly lying, sitting and standing—that’s a number worth assessing. And self- reported number of skipped meals? Or frequency of purges? Or binges? Or number of hours or compulsive exercise? And of course there’s caloric intake relative to need. These are numbers that may tell you something about a patient. These numbers are worth counting.

I realize there are not unlimited funds for care. But perhaps listening to the professionals who can really assess their eating disorder patients—aside from relying on simple weight and BMI—might save you more money in the long run. You’ll collect no premiums from our patients who lose their eating disorder battle.

Sunday, April 12, 2015

Good food, bad food and calorie counting? What kids really need to learn.

Nutrition education in schools worries me. My sentiments have been echoed
on the Academy for Eating Disorders list serve and among peers from SCAN--the Academy for Nutrition and Dietetics (AND) subgroup populated by progressive thinkers.
A very different path.

To change the direction of how kids are being taught, I've written this piece. Share this locally, in your schools, and virtually. Use it, and use it fully, including my name, please. Thanks for spreading the word and working for change.

Good food, bad food and calorie counting? What kids really need to learn.

By Lori Lieberman, RD, MPH, CDE, LDN

In an attempt to tackle the “obesity epidemic” kids, educators and parents often receive well-intentioned but potentially harmful messages to manage eating. (1)Calorie-counting apps and black and white messages about what’s healthy to eat can be problematic. Kids, parents and educators need practical, realistic strategies to add to their toolbox. Help kids learn to self-regulate their food intake utilizing current knowledge on eating behaviors and the food environment and know the damage of deprivation-based diet approaches.

One size does not fit all!

We are educating the masses—kids of all sizes and weights, including those who are sedentary and those with very high needs given their size, needs for growth and for sports—and kids with personality traits who tend to be very literal, anxious or perfectionistic. Consequentially, food messages should be presented to serve all without harm.

Good food/bad food

Nutrition messages need to shift from the ineffective ‘good’ versus ‘bad’ nutrients and foods, to factors that impact the ability to self-regulate intake. Directing individuals to restrict their fat intake can backfire. (2) Labeling sugar as ‘bad’ and setting calorie budgets fails to control weight in long term. (3) Evidence shows that perceiving a scarcity of food and deprivation from restrained eating creates greater problems (4) and contributes to eating disorder development. (5)

Calorie counting 

Calorie counting is ineffective in the long run and conflicts with utilizing hunger and fullness—essential for managing energy balance. It fails to teach kids about major obstacles to changing eating—eating behaviors and environment. Counting calories has little positive impact on improving eating habits and weight. (3,6,7)In one study kids who began dieting had a significantly higher likelihood of developing a serious eating disorder. (5)


Portions are also not one-size fits all. Current materials (1) refer to appropriate snack sizes but for underweight kids, competitive athletes, and those simply with higher needs, these may be inadequate. Many teens require more than the current campaign’s recommended single serving of most snacks and greater than the 100 calories encouraged as ‘moderate’.

Sit, structure, separate, sense

Let’s shift the focus to what works—a mindfulness approach addressing simple, achievable eating behaviors. (8,9)

Address these key behaviors to improve intake and portioning of food, applicable to all children and adults.
  • Sit in the kitchen or designated eating space, at a table or counter when eating.
  • Structure the day to include 3 balanced meals and snacks. Include an early breakfast and be prepared—keep snacks available and give kids a chance to eat when they need to. Encourage delaying not forbidding ‘seconds’, allowing time to sense fullness. Allow eating later when hunger is present.
  • Separate eating from distractions, like TV, phone, homework, computer; distracted eating increases intake. Separate food from sight; keep food off the counters to prevent triggering eating.
    • Separate food from its package! 
    • Plate it.
  • Use your senses
    • See, smell, feel, hear and taste your food—whether it’s a cookie or cantaloupe. You’ll be more satisfied when you really pay attention to and enjoy what you’re eating.

Encourage positive additions and messages to support a healthy diet.

  • Include 3 or more cups of milk, yogurt or milk alternative (such as soy milk) for protein, calcium and vitamin D.
  • Choose fruit frequently. 
    • Select from fresh, frozen, canned in juice. Don’t forget dried fruit—a convenient, satisfying, nutrient and fiber rich snack.
  • Vary the Vegetables: shred them, steam them, sauté them, dip them, puree them into soups or smoothies. 
    • Get them in all colors. Include more than a cup a day.
  • Get real! Choose more foods that are processed less, including nuts and seeds, beans, whole grains and fresh fish/meats.

Let’s spread a sensible, more sensitive message to promote health among school age kids of various sizes and needs. Advocate for diversity of foods to normalize intake for a diet rich in nutrients and adequate in calories. Let’s focus on learning to encourage portions that fit the individual’s needs by integrating both mindfulness and environmental strategies. And let’s accept that normal eating includes having foods at times simply because they taste good.


2. Wansink, Brian, and Pierre Chandon. Can “low-fat” nutrition labels lead to obesity? .Journal of marketing research 43.4 (2006): 605-617.
3. Lowe MR, Doshi SD, Katterman SN, Feig EH. Dieting and restrained eating as prospective predictors of weight gain. Frontiers in Psychology 2013;4:577.
4. Mullainathan, S, Shafir, E. Scarcity.New York::Times Books, 20135. Lowe, M. R., Thomas, J. G., Safer, D. L. and Butryn, M. L. (2007), The relationship of weight suppression and dietary restraint to binge eating in bulimia nervosa. Int. J. Eat. Disord., 40: 640–644. doi: 10.1002/eat.204056.
6. Downs, Julie S., et al. "Supplementing menu labeling with calorie recommendations to test for facilitation effects." American journal of public health 103.9 (2013): 1604-1609.
7. Ely, Alice V., et al. "Differential reward response to palatable food cues in past and current dieters: A fMRI study." Obesity 22.5 (2014): E38-E45.
8. Beshara, Monica, Amanda D.Hutchinson, and Carlene Wilson. "Does mindfulness matter? Everyday mindfulness, mindful eating and self-reported serving size of energy dense foods among a sample of South Australian adults." Appetite 67 (2013): 25-29
9.  Supporting Intuitive eating section, Linda Bacon