Friday, July 4, 2014

Declare Your Freedom: Gaining independence from diets and disorders.

This stormy day, oppressed by the weather and the limits on my freedom to enjoy the outside, I find myself home, contemplating your freedom. It’s July 4, a national holiday in these united states.  Fortunate to have been born in the US, never oppressed by my government, I take for granted the freedoms that some yearn for. Yet through my day to day interaction with patients, I’m painfully aware of how enslaved many are by their own thoughts and actions—though admittedly not by their choosing. Most wish not to suffer, but feel entrapped; they are overwhelmed by the rules which dictate what’s acceptable to eat and the intrusive thoughts and judgments about their eating and activity. They irrationally fear anything from white flour and sugar to fats. Sometimes the type of foods is not the issue, but the portions are. At first glance, a food record may look impressively normal—until I probe about quantities consumed—the limited bites here and pieces there that are actually consumed.

“We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness…”

While this preamble to the Declaration paves the way to addressing national independence, it’s predicated on individual rights.  Yet how many of you acknowledge these basic entitlements?

Equality. Do you feel that your needs should be considered equally with those around you? Do you consider your needs—for time for yourself, for eating when you need to and what you feel like? Do you feel deserving of pleasurable dining experiences? Or is such pleasure only for other people to experience?

Life. A full and satisfying life. Yes, you are deserving of this too. A healthy life, allowing you to engage in whatever you enjoy. A life not eaten up by self criticism.

Liberty. Freedom from food rules (barring medically critical ones, like avoidance of an allergen that causes a reaction). And liberation from mental hoops you jump through whenever you consider food and eating. Must you feel guilty if something tastes ‘too good’?

The pursuit of happiness. Can you even imagine what this is? Do you remember what you were passionate about before food and diets snatched it all away? What do you dream about when you free yourself from the bitterness of your diets, of your restrictions, of your unrealistic expectations for size?

Freedom can be scary. But independence from both diets and disorders is the sure way to support life, liberty and the pursuit of happiness. I don’t think it’s simple. But taking a stand for change is a valuable first step.Seek out supports--an experienced therapist, dietitian and medical provider can help. But also use your close connections--don't be afraid to ask loved ones for help. Become informed--there's a wealth of posts on this blog on nutrition realities and great links to other reputable bloggers and websites, as well as my books, drop the diet and food to eat, coauthored with ASPIRE's founder, Cate Sangster.

What steps will you take to declare your independence?

Thursday, June 26, 2014

Exercise: Enough or too much? Knowing when to change gears.

Are you exercising enough or too much? Do you feel you need to be doing more? It’s often hard to judge for yourself. So take a look at these cases, modified from patients I encountered this past month, and see what you think:

Regardless of the activity, do be sure to listen to your body's needs!
  • A competitive skier, who spends 5 hours/day skiing and 90 minutes/day hiking;
  • A college student who runs 30 minutes, 4-5 times/week;
  • A biker who biked 55 miles one day, 107 miles over 3 days;
  • A coach who worked out at the gym 6 days/week, and spends 12 hour days physically active coaching.
  • A woman with anorexia who runs 3-4 days/week for 40 minutes.

If you’re thinking: “It depends”, you’re right. So here are some more details:

  • The skier came to see me wanting to gain weight to improve her strength and performance. She was fully on board with gaining weight and with eating more.
  • The college runner? He pushes the intensity and distance when he’s overeaten or binged and then also overcompensates by eating less.
  • The woman with anorexia? She has been successfully cutting down from her daily, injury-inducing hour-plus runs, while simultaneously increasing her food intake.
  • The sports coach? His activity stays constant regardless of his intake. And his intake hovers between 300 and 400 calories per day. And his weight is stable.
  • As for the biker? That’s me. I’m not making excuses but my husband got us lost on a ride last Sunday and we did way more than planned in our training for a 150 mile fundraising ride; but I did need to get the training in and was planning on a 40 miler. Along the route, after a full breakfast I had a delicious scone—and a generous lunch out. I acknowledged my poor planning when I petitioned my husband to part with one of his bars. He gave in and I ate it, and I was quite thankful.

Now what do you think? Is it becoming clearer?

It’s difficult to fairly evaluate activity levels simply by knowing the type of activity and the duration—whether or not you have an eating disorder or disordered eating. Without evaluating the bigger picture of thoughts and intentions, that is. The skier—with her very high activity but drive to eat enough for performance and health—is the least of my concerns—as long as her eating changes support her intentions. But the coach and the college runner? Activity is clearly used inappropriately in their cases.

But what if intentions are healthy—you want to maintain your healthy weight or even lose weight from your current higher than usual and healthy place, perhaps to include a moderate level of activity? Yes, I do support increased activity in these patients. With caution, though, in those with a history of eating disorders. And I support increased activity to help improve elevated blood sugars and cholesterol levels. But if you spend your waking hours premeditating how to work out to justify your eating, that’s a problem. If you perceive that it’s healthy to work out—for instance, you have intentions to be a healthy person—but your food intake falls short, resulting in low energy, irritability, early fatigue, inappropriate weight loss or slowed metabolic rate (with low body temp and heart rate)—then those good intentions clearly aren’t enough.

A healthy mind and body

Compelled to exercise at midnight because you can’t sit with the cookies you ate? It’s not enough that your vital signs are stable or that your weight is “better than it used to be”. No, there’s a problem here. Obsessed with the calorie displays on the treadmill, or the number of steps or miles on your pedometer or FitBit? Maybe it’s time to rethink your activity.

From my clinical experience, I’ve seen more previously sedentary people give up moderate activity when their sole goal was dropping pounds. Patients who exercise strictly to manage their weight are challenged to maintain their activity. If they didn’t drop weight in spite of exercising, they think: “why bother”; they ignore all the positives like the sense of achievement in having followed through with their goal, the improvement in mood and in sleep. They forget how nice it was to have time for themselves—or to connect with others around something other than eating. They fail to remind themselves about how their endurance or their strength has improved. So they drop the exercise.

Ok, I also ride to get to great places. Provence, France
I don’t ride to lose weight. I love the outdoors and love the feeling of the breeze on my face, like a dog with his snout poking through the car window. I like how it feels when I’ve accomplished a ride, but also how it feels while I’m riding; yes, I even like the journey. I enjoy the camaraderie of riding with company, but sometimes prefer to go off by myself. And my weight? It tends to remain within a couple of pounds throughout biking season. No doubt, because I am mindful to eat enough, stay strong while cycling—sometimes even when I don’t notice hunger. Sound crazy? There are times—like immediately after my ride or when we take a rest, that stomach hunger isn’t clear. Yet the fatigue might be stepping in, a sign of hunger gone too far, which can be resolved with nourishment. Sometimes the act of pushing fluids to stay well hydrated limits my perception of hunger. The high intake of water or Gatorade can buffer your hunger, making it more challenging to know that eating is necessary.

But if I did ride to support stabilizing a climbing weight, or to turn this trend around—would it be a problem? Perhaps not. Exercise, per se, is not the issue. But using it while denying adequate nourishment surely requires some help.

Back to my patients

Sure, the frequency and duration of activity might be a red flag, but we really need context to gauge its appropriateness.
The skier I have little concern about—in spite of her very high and frequent exercise—because it appears that her head is in the right place. And I was met with no resistance when encouraging practical calorie boosting recommendation to increase her energy and her weight.

For the coach with a very low calorie intake, his weight might be stable, but his intake is very restrictive. And he has a history of losing significant amounts of weight combined with unhealthy thoughts and behaviors—that’s a major problem. There should be no physical activity for him—at least until his intake increases significantly. Exercising, in his case, will only break down the muscle he has long worked to develop.

What are you hoping to achieve by working out?
The 30-minute college runner’s activity concerns me a great deal. Clearly it’s not the amount of exercise, but the way in which it’s used when he is uncomfortable sitting with the distress of eating, when he perceives he’s eaten too much. Yet I’m less worried about my patient running with anorexia—as long as she continues her progress with eating enough and maintaining her weight and medical stability—which she has done beautiful well with.
In some instances it’s quite clear that the exercise prescription needs be refined. If your weight or vital signs are falling out of range—something has to change, starting with reduction or elimination of activity; and if your eating becomes more restrictive, even if your weight is stable (due to slowed metabolic rate with undereating + exercising), activity needs to go. Really.

Many individuals can include exercise and be healthy—even if the exercise supports weight loss (in someone for whom weight loss is deemed appropriate by their medical team).

Talk to a therapist, your doctor, or your dietitian about your activity level. But don’t forget to share your thoughts—not just the details of duration, frequency and intensity of your activity.

Monday, June 9, 2014

Gluten Free or Gluten Freedom? You Decide. How a Gluten Free Diet Impacts Weight & Health

Do you really need to give this up?
Go ahead and eat how you’d like. Want to only buy organic produce? It’s your call—just don’t ask me to foot the bill. Into whole grains? Vegetarian or Vegan? Serious meat eater? Really it’s not for me to judge.

But you know I can’t just leave it at that. My concern is that if you choose to eat in a particular manner that it be without unnecessary rules that negatively impact your wellbeing—either physical or mental. And I’m concerned when you and others get caught up in the supposed health hype of the day, only to learn the hard way that it just wasn’t worth it.

Let’s talk gluten free

Yes, I even add gluten to my breads!
I hate pain and suffering. So if you have celiac disease and are suffering the effects of this autoimmune condition—this reaction to gluten that strangely results in self destruction of part of your small intestine, there is no diet I’d rather see you follow. Please follow it 100%. Period. Avoid cross contamination from wheat, rye, barley and its derivatives. Read labels and avoid it like the plague. And contact a Registered Dietitian who knows the ins and outs of following this diet to focus on what you can include, not just what you need to avoid.

And I hate deprivation. I mean, denying yourself great, fresh gluten-rich breads and hearty wheatberries and barley (see recipes from Food to Eat and Drop the Diet) to me is painful. I simply don’t see the why if you don’t have celiac disease. If you don’t have celiac choosing gluten free does nothing to enhance your wellbeing nor help you manage your weight. But you’re not alone for believing it will. At my 30th college reunion recently, I confessed my profession to a classmate, a very bright MBA, Ivy educated attorney. This smart and sensible guy hopefully queried “Do you think I have to stick with this gluten free diet I’m on? Would I be okay if I just gave it up?” Yes, poor judgment knows no IQ limits! So LA classmate, this one goes out to you!

But aren’t there benefits of a gluten free diet?

What Gluten Free will do to your weight

Or these?
Start following a GF diet and no doubt you’ll be much more mindful of what goes in your mouth—because you have to be. You read labels and you think before you eat. And that’s a good thing from a weight management standpoint. It’s hard to be an impulse eater while following a GF diet. Besides, how many rice cakes or GF cookies can you really eat? But if you don’t cook much and you rely on ready-made GF products, the quality of your diet may suffer—along with your weight. GF breads are more calorie dense, as they are missing the scaffolding that gluten provides to assist leavening. And GF breads and other products are often (although not always) lower in fiber—there’s no whole wheat, or rye or barley. (Of course you can add quinoa and brown rice, but these you need to prepare.)

Or this?
If you are following a GF diet because of celiac disease, then your weight may very well increase; with poorly controlled celiac (think pre-GF diet), there is malabsorption. You eat, but much of what you eat passes through without being incorporated into your body. Resolve the underlying issue by avoiding the culprit—gluten—and you will restore normal absorption and get all that you eat. And yes, that may result in some (perhaps very appropriate) weight gain.
But if you’re like the majority of individuals following a gluten free diet, you haven’t tested positive for celiac (through a blood test or via an endoscopy and biopsy of your small intestine). Rather, you follow this diet for a range of other reasons.

A tale of 2 RDs

My favorite, homemade rugelach. Recipe on this blog! Not GF!
It’s amazing what desperation will do. When the medical community fails you—when they have no answer for your symptoms or no cure for your disease, alternative, non-evidence based practices look very appealing. And what’s to lose? Yes, even rational thinkers can be sucked into the hope that this may solve our problems. As I’ve written about previously, my diagnosis with MS 12 years ago lead me to the gluten free diet. Anecdotal evidence abounds and the theories seemed believable. So yes, I followed a gluten free diet—meticulously. Labels were read and dining out was largely avoided—except for at establishments that took gluten free seriously. I was cautious about cross contamination as well—I had my own jar of preserves and butter—no gluten rich crumbs were to enter my body.

And then I stopped. It wasn’t just that I thought about my favorite breads and baked goods I could no longer eat—that was a challenge— or the time it took to prepare everything from scratch—I do that largely anyway. But when my 3 month MRI showed more new damage to my spinal cord it was a done deal. The GF diet did nothing for my disease. Mind you, I’m not blaming it for the worsening of my condition during that time period; the disease progression coincided with the GF diet, but there was no evidence that it was caused by it! Anecdotes like mine are rarely posted. You generally just hear the success stories, leading you to believe only the positive.  

Which brings me to another RD

Kay struggled with many of the classic symptoms you hear about, attributed to gluten intolerance—GI cramping, low back pain, diarrhea, fatigue, to name a few. And regrettably, her doctors failed to screen her with the simple blood test that picks up the majority of sufferers with celiac, nor suggested an endoscopy to take a look at what was going on. Rather than delay, Kay began a gluten free diet and by her report started to get relief from her symptoms within days—not fully, but significantly.

In Kay’s situation, this was likely celiac—just never diagnosed. I often see patients, though, who believe they have a gluten problem who likely don’t. One recent patient had been avoiding all gluten for many months, yet continues to have diarrhea 3 times/day. If it were a gluten issue, symptoms would certainly be improving. Another patient believes she fails to tolerate gluten and reports following a GF diet and feeling great. But a closer look revealed lots of hidden gluten sources—like on a daily basis. No, avoiding gluten wasn’t what was helping her—because surely she only perceived she was avoiding it. Rather, the placebo effect just might have been working its magic.
Dessert, not bread, from Tartine, San Francisco. Yum.

So why share all this? Because there is so much misinformation out there that it’s easy to get sucked into the craze of the days. And I believe that you should be educated about the impact of your diet choices—both physically and mentally—so you may make informed decisions.

And no, I have no financial interest in gluten-rich products, but I do love my favorites including Tartine (San Francisco), Seven Stars (Providence, RI), Guillaume (Montreal, Canada), and Clear Flour (Boston, MA). And of course Kings Highway Bagel in Brooklyn, NY, where I grew up. What are your favorites?

And for those who follow GF, what are your favorite, certified GF baked goods? Please share!

Tuesday, May 20, 2014

Fat and Always Hungry? No, cutting the carbs won't cure your weight struggle.

It’s 10 AM Sunday and quite frankly, I’d much prefer to be leisurely finishing my coffee after my blueberry pancakes-topped with a dollop of vanilla yogurt and heated real maple syrup. But Ludwig and Friedman’s Always Hungry? Here’s Why piece in the NY Times  today compelled me away from my plate.

To start, let’s get a title change, please, let’s say Here’s What We Think based on virtually no research at all. This is an opinion piece stating two doctors’ theories about why we get fat and what we should do about it. Period. But with the sensational image and title you, like most people, will be drawn into more myths about weight management.

Here’s where we agree—and disagree

Do you just eat bread for your meal?
Agree: There are factors outside of your control that may contribute to your size. Genetics and the presence of fat cells exert their influence. Once you have gained to a higher weight with an increase in fat cells, you will be fighting an uphill battle to lose that weight and keep it off—without disordered behaviors.  And it’s not your fault. For more on this see Professor Lowe’s work on weight suppression and bulimia. 

Agree: Metabolic rate slows down with food restriction—that’s indisputable from the research. Obese individuals who have undergone extreme low calorie diets will have a lower metabolic rate as a result of the decrease in muscle mass that results, compared to same weight controls who had not dieted. Less aggressive approaches to dietary activity change tend to spare the muscle loss and help maintain metabolic rate.

Before dieting...
But the authors state that metabolic rate also decreases with weight increase:  “…factors in the environment have triggered fat cells in our bodies to take in and store excessive amounts of glucose and other calorie-rich compounds. Since fewer calories are available to fuel metabolism, the brain tells the body to increase calorie intake (we feel hungry) and save energy (our metabolism slows down).” Yet there appears to be few examples of this cited in the scientific literature, with the exception of a possible rare genetic mutation, not likely the cause of obesity in the greater population.

And the temporary slowed metabolic rate seen with weight loss has been demonstrated to be reversed with weight restoration in the obese (albeit a small sample size studied) and more dramatically in those who are underweight with anorexia, summarized well by Carrie Arnold in ED Bites.  In practice we see dramatic increases in metabolic rate—calories burned and required each day—with weight gain in anorexic individuals at least until they have restored to their healthy state.

Agree: Insulin increases nutrient uptake and in excess causes weight gain. And carbohydrate results in an increase in insulin secretion.

Disagree: Ludwig and Friedman’s leap that foods that increase insulin secretion should therefore be reduced or avoided for weight management is faulty reasoning—unless there is a documented underlying metabolic abnormality. A relatively small percentage of the total population has PCOS or hyperinsulinemia—a faulty regulation of insulin. For these individuals, addressing carbohydrate amount or glycemic load (impact of a food on raising blood sugar) has a positive impact. But there’s no evidence that a low carbohydrate diet is any better at long-term weight management than any other dietary intervention. 

In addition, while individual foods and their glycemic index—the amount they raise blood sugar (and therefore subsequent insulin levels) may seem valuable, practically speaking they have less impact.  You see, we generally don’t eat single nutrients like carbohydrate. Rather, we eat mixed meals, containing protein, fat and carbohydrate. And in this combination, the impact on insulin levels that even the white potato might have if eaten solo is minimized with that piece of chicken and the added olive oil or nuts in the salad.

This banana chocolate pastry has plenty of fat to lower its glycemic load!
(From Tartine Bakery, San Francisco)
And did you know that many of the villainized desserts have a minimal impact on insulin levels? Peanut M&Ms aren’t much different than lentils (see glycemic load—the best measure of blood sugar impact which considers portion) and cheesecake made in it’s full fat recipe will no doubt come in quite low as well.

I don’t share this to promote a diet full of low nutrient, processed foods. Rather, to make a point. Viewing foods as good and bad will do nothing to help you manage your weight—nor your mental health. In fact, there’s plenty of evidence that feeling deprived by denying yourself foods you enjoy leads to rebound overeating.

The authors also state “what if it’s not overeating that causes us to get fat but the process of getting fatter that causes us to overeat? Unfortunately, I think they have oversimplified their hypothesis.

Sure, having more fat cells may contribute to our struggle if attempting to lose weight. But it’s not simply a macronutrient issue. Being larger presents more challenges for being active; larger individuals report being subjected to fat shaming while exercising—presenting its own challenges.

Rebound binge eating following starvation—think dieting—has been well documented as well. All or nothing thinking—what I call the “what the heck effect” results in overeating when you believe you’ve already blown it.

Our over-scheduled lives with multiple competing needs don’t help us either. Multitasking while eating makes us less aware of what we are consuming and contributes to overeating. And the larger the containers or plates we are eating from, the more we will over-consume (see Prof.Wansink's extensive work on this).

Time and money constraints add flames to the fire—we take little time to plan, shop and eat mindfully. In fact, our cognitive ability is compromised by these stressors and worsened when we diet. Perceiving that we won’t have enough food to meet our wants or needs, referred to as scarcity creates a range of secondary effects. Poor decision making, impaired ability to organize and follow through and hyper-focusing on the immediate benefits without considering the long term consequences of food choices are well researched and described in the fascinating new book, Scarcity.

Unrealistic goals set by national organizations  and by ourselves adds to the problem. If 150 minutes per week plus 2 days of muscle strengthening/wk is unattainable, why bother?

Further, the food industry isn’t all bad. (And no, I am not a paid consultant to any food company!) They are the ones who bring us the convenience of precut and cleaned vegetables and canned, high fiber, low glycemic legumes. They allow us the convenience of reheating frozen brown rice and quick cook barley. And they have given us a range of milks in every fat percentage we could ask for, and yogurts of every style—Greek and higher protein, sweetened, full fat, real sugar, artificial sugar and no added sugar. But many of the choices remain ours.

So what’s the solution to our climbing weights beyond a healthy range?

  • Move away from dieting and that sense of scarcity.
  • Set realistic goals for change—be it frequency of a home-cooked meal or a visit to the gym.
  • Begin to work on behaviors; separate eating from distractions, and delay seconds (see older posts on this blog for help)
  • Include a range of foods and nutrients. Include high fiber, whole grains and legumes, fruits and vegetables, nuts and healthy oils; protein-rich foods such as poultry and fish, and less frequently red meat; low fat milk and yogurt and modest amounts of cheese.
  • As part of a balanced meal, by all means enjoy your rice, breads and pasta, too. And you know my stand on baked goods! All or nothing approaches to dietary change will get you nowhere.
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