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

Monday, February 23, 2015

What doctors must know about eating disorders.

I want your input. I need to hear your voices. For EDAW 2015, I have volunteered to present to two medical residency programs—one in Boston, MA and one in Providence, RI on what doctors need to know about eating disorders.  I've incorporated recommendations from twitter responders and from Aspire, but I welcome more input. Here's what I have to share with new doctors so far:

  • Avoid the ‘Don’t ask, don’t tell’ approach. Patients rarely volunteer behaviors they feel ashamed of—bingeing, purging, diet pill and laxative abuse.  So providers need to ask. Nicely. Casually. Non-judgmentally. Include basic ED screening questions at routine visits.
  • Early action is not just for college admissions. Eating disorders are best identified early and treated promptly. We wouldn’t simply wait it out to see if blood sugars simply turn around in a patient with type 1 diabetes. Take eating disorders as seriously as you would cancer, or
    The time is now for improving medical management
    of eating disorders.
    diabetes, or heart disease. Because like these medical conditions, they cause physical damage, and impact emotional wellbeing. And did I mention that left untreated they can be fatal?
  • Relying on size is a seismic mistake. People of all sizes suffer from eating disorders. And because eating disorders in those of “normal” weight are often missed, they may be more chronic and challenging to overcome. Patients with anorexia can have high BMIs; they severely restrict their intake, are ruled by food rules and fear weight gain; their restriction impacts their ability to function, their mood, their blood pressure, body temperature, blood counts and thyroid level, fertility, bone density, and GI function.
  • ED sufferers want help. People with eating disorders ultimately want to be free of their disorder. They are not just being difficult. They may also be struggling with depression, anxiety and OCD making recovery more challenging. They are
    suffering with their symptoms making day-to-day life unbearable. In fact, the risk of suicide is higher in those living with eating disorders and is a major cause of death in this population.
  • Be careful what you ask for. Before recommending that your ‘overweight’ patients lose weight, do some assessing.  Has their weight or weight percentile been normal for them? What behaviors might be better addressed versus focusing on their weight? Diets can be the tipping point, precipitating an eating disorder. Striving to achieve and maintain a lower than usual weight contributes to maintenance of eating disorders.
    You can't simply tell by appearance that
    someone is suffering.
  • Guys (yes even straight guys) get eating disorders. Seemingly healthy, fit, guys, and overweight boys and men live with eating disorders. Like girls and women, they may restrict and be fearful of gaining, binge eat, purge, and compulsively over exercise. EDs have no gender limits.
  • Eating disorders may start in preadolescence, or at age 20, or in the 40s.  Eating disorders don’t expire when kids reach adulthood, or when adults mature. Individuals with EDs may first present for care after decades living with their ED or may have a late adult onset during a transition period in late adult hood.
  • Read between the lines and ask the right questions. Please don’t praise a patient’s weight loss. Would you say great job if they lost due to cancer? Do focus on reinforcing healthy actions, not numbers. Rather, ask:
    •  "What kinds of changes have you made?" 
    • "How do you feel?" 
    • "What percentage of your thoughts are spent thinking about food and eating?"
    • "How’s your energy level?" 
    • "How are you managing with these changes?"And note that healthy eaters are not always so healthy. Ask why your patient became a vegetarian/vegan. Why are they following a gluten-free or low carb diet?
Families play a critical role in
supporting a child's recovery.
  • Parents are necessary supports for recovery. Overwhelmingly, parents need to be brought in to assist recovery. And the only thing we can blame parents for when it comes to eating disorders is their genes. 
  • Eating disorders are serious mental health conditions. They have genetic, environmental and nutritional underpinnings. They don’t just “run their course” or become “out grown”. They require treatment by experienced providers. ASAP. Waiting may be lethal.
  • If you don’t know, please ask! Check out AEDs medical resource guide and this. Seek out providers to collaborate with who are part of national or regional eating disorder organizations like AED, NEDA, iaedp and MEDA.

Please share this with your medical providers. And with your friends. And twitter followers. And with your Facebook friends.

Eating disorders require education and a break from the commonly help practices and beliefs. And you can help make it happen.

Thanks again to those who have already shared their ideas that were incorporated into this post.