Pages

Monday, December 26, 2011

Struggling With Your Eating? Carrot Cake May Be The Answer.

I ate too much. I kid you not. Eight days filled with fried foods is weighing me down. And while I don’t celebrate Christmas, it happens to be my husband’s birthday. So I made the obligatory carrot cake with cream cheese frosting—his favorite—a total yum— and probably ate a bit more than was necessary. And that was after the Indian food we had out—shared lentil soup, appetizers—the works.

Having my jeans fit rather tightly can be challenging even if I needed to gain some weight—which I don’t. Somehow, there’s just no positive reinforcement in our culture for having your waist band cut into your flesh—even if it’s truly a sign of progress, of necessary weight gain for recovery. Growing out of your clothes (unless you’re an adolescent, entitling you to indulge in the newest fashions) yields little benefit in our society. But in my case, that’s beside the point. My personal goal is maintenance, within my normal and healthy weight.

Yes, even nutritionists can, and do, overeat at times. Of course I know better, yet I found myself grazing on salted, roasted cashews rather mindlessly while mixing up the carrot cake batter. And serving the cake from the table? Big mistake. It called to me, a mere arms-distance away. Those skinny, knife thin slivers don’t really count, do they?

What did I resolve when I woke up this morning? First, I wouldn’t dare consider weighing myself—no need to see what I already knew. I might have considered a bowl of bran flakes or oatmeal. But I really felt like having the freshly baked bread I made the night before. (I was rather productive on Christmas, wasn’t I?) 

Rather than have the cereal while yearning for the bread, I decided to have what I really wanted. And so I cut a thin slice of this rather dense, wholesome bread, chock full of oats and flax, figs and walnuts, seasoned with anise seed, and had a bowl of yogurt and fig jam to go with it. And, had my coffee, of course.

What I didn’t resolve was to make up for the extras consumed in the many days before. I did not resolve that I blew it, that I shouldn’t even bother, because it’s useless. Or, that the leftover carrot cake was to be trashed, so that I wouldn’t eat it again. I wouldn’t dream of such a thing (besides, my husband would probably fish it out of the trash barrel if I did). And if I did, it would only reinforce that cakes were something I wasn’t entitled to eat, so it was now or never when they were within my reach. This, of course, would only lead to overeating. I did, however, slice it up, wrapping each slice individually, and froze it.

I did not resolve to skip my usual workout, or my walks with Mica (you know who he is, by now, right?), because “why bother?” I love my treks through the woods by my home. It’s hard to know who gets more excited at the sight of a squirrel—me, or Mica.

Yes, it’s a process. We all need to remind ourselves of what is in place, rather than focusing on where we slipped. This morning’s Skype session with a client overseas addressed, in part, expectations. It came naturally to Anna to focus on the fact that her weight had not yet improved. But the positive changes she has been making were far less obvious to her, and certainly more difficult to measure. She needed to recall that having two chocolates, only two, was in fact, progress. Yes, there was a time, not too long ago, that she would have laughed when I suggested this was possible; chocolate was something to be avoided, when trying to manage weight, for fear that once she started she’d have no control over stopping.

Being able to distinguish her hunger—and her fullness—has also been a major recent achievement. Previously, without this awareness, she was left without the tools to self-regulate food intake. One night this week, she chose to have a snack, responding to this hunger, prior to dinner being ready. As a result, she was left with little hunger at mealtime. She gave herself permission to delay dinner—rather than eating it at the planned time—another step forward in listening to her body’s signals. She knew she could, and would, eat again later when she needed to. The fact is, as a result, she ended up being more in control of her eating, versus overeating.

But if the only goal is pounds lost, then she made no progress this past holiday week at all. Anna needed to revisit the house-building analogy, to shift her focus on what’s truly important at this stage of our work together. Building her foundation is a necessary first step to changing her relationship with food—and ultimately her weight.

As for me, I did have a lighter dinner this evening—a root vegetable soup, accompanied by the sliced homemade bread. And, I mindfully enjoyed every bite of the microwave-defrosted slice of carrot cake. 


And I’m feeling quite good.

PS: Here's the recipe some of you requested!

Joel's Birthday Carrot Cake
Ingredients
2 cups flour
2 cups sugar
2 tsps baking soda
2 tsps cinnamon
1/2 cup oil
1/2 cup unsweetened applesauce 
3 eggs
2 tsps vanilla extract
3 cups finely grated carrots
1 cup walnuts
1/2 cup shredded sweetened coconut
3/4 cup drained crushed pineapple

(See Cream Cheese Frosting Recipe below)

Preheat oven to 350 degrees F. 
Line 2 round cake pans with wax paper, then grease or spray them. (a  13 X 9 inch pan works fine too, but doesn't look as awesome!)
Blend the dry ingredients in a mixer.
Add the next ingredients, through vanilla, beating thoroughly.
Then fold in remaining ingredients.
Pour batter evenly into the two pans.
Place in middle rack of oven.
Bake approximately 1 hour, or until the edges pull off the sides or a toothpick comes out clean when inserted into the center of the cakes.
Let cake cool 10 minutes in the pans. Then flip them over onto plates or cake platter. They should fall from the pans with ease.
Peel off the wax paper and let cool an hour.

Cream Cheese Frosting

12 oz reduced fat cream cheese or Neufchatel (brick form), room temperature
4 Tbsps (1/2 stick) unsalted butter, room temperature
1 1/2 cups confectionary sugar
1 tsp vanilla extract
2 Tbsps milk

Blend it all until smooth, without lumps, and it's ready to use.
Frost one whole cake. Then drop the second cake onto the first and frost top and sides.

Sit down with a slice, and enjoy every bite. Remove the rest from the counter, by slicing and removing the pieces from view (freezing is ideal!)

Monday, December 19, 2011

This Holiday Of Miracles—Ancient Wisdom About Managing Your Eating

Taking back control. Rededication. Surviving persecution and abuse.  Triumph after being restricted, forbidden from following your own path. Your prized possession, quality olive oil, gets you through, for much longer than you ever believed it could.

These phrases describe the festival of Hanukkah, yet I can’t help but repackage them as a recipe for moving forward with our eating—both, during this holiday season and beyond, for Jews and non-Jews alike.

First, here’s my very brief summary of the holiday (for a more complete story, check out Chabad and Wikipedia). 

Hanukkah celebrates the rededication of the Second Temple in Jerusalem a long, long, time ago, more than 21 centuries ago. Following a rebellion against Hellenization, after being persecuted, denied following their own religion, a group of rebels fought back and regained control. They cleansed their temple, and wanted to light their 7-branched menorah, the candelabra, but there was only enough of the purified olive oil required for this ritual lighting to last one day. And yet, voila, it lasted all 8 days. This was great cause for celebration, and what better way than include a lot of fried food?

Some summarize our history more like this: They tried to kill us. They couldn’t. Let’s eat.

Thus, the tradition is to celebrate this triumph over oppression and the miracle of oil. And not just any foods, mind you. The Hanukkah mandate is eating oil rich foods, traditionally white carb types—it’s enough to cause panic among the health conscious and weight-focused.  We eat fried latkes (aka potato pancakes), with sufganiyot for dessert (aka doughnuts). And did I mention this lasts for not one night but for 8?

Regardless of your particular culture or religion, we are all confronted by food challenges this season. And while I have addressed this subject in various posts previously, http://dropitandeat.blogspot.com/2011/11/taking-charge-practical-strategies-for.html, http://dropitandeat.blogspot.com/2010/12/recovering-from-slip-coping-with.html, I thought I’d give a bit more support to get you through this challenging (yet potentially joyous) season.


Balance

From my own experience, I’ll tell you that eating latkes or similarly fried foods, as the main entrée, isn’t going to work for me. I have no problem with including oil in my diet (see http://bit.ly/dOZNqH  and http://bit.ly/uqnq92), but I need to have some balance. All too often, health-promoting types (nutritionists included) get stuck focusing on individual foods or nutrients, neglecting one important fact—we don’t eat single nutrients or food items. 


And we don’t need to get all nutrients from a single food! No, we eat foods together, providing us the opportunity to balance our meals, and our day’s intake, to stay healthy.


Take control of portions

Yes, Hanukkah at my house will include latkes, on more than one night. There will be the traditional potato and onion ones, and my more recent favorite—a parsnip-potato pancake. Perhaps I’ll even try a cardamom leek fritter recipe I stumbled upon recently. But served as the whole meal? I don’t think so. So what will I do? I’ll serve them with a soup and a salad, some lighter fare. On one night, I’ll also serve my homemade sufganiyot, these two-bite delights that really satisfy; at least the portions are small. The bottle of oil, in my home, lasts way more than eight nights, I’ll add. While the sufganiyot are deep fried, I’m light handed pouring oil for my latkes preparation.


Choose what you enjoy. Enjoy what you choose.

Wondering how you’ll manage the Christmas bird or roast with all the fixings, with a yule log for dessert, too? You, too, can add some balance, picking and choosing the richer and the less dense items. But do include foods you enjoy! Otherwise, you may find yourself indulging when you aren’t hungry later, making up for your feeling of deprivation.

And please don’t forget to leave leftovers! Better to enjoy the extra food when you aren’t stuffed; won’t the cake and pie taste better when you’re hungrier? Perhaps for breakfast the next morning? Yes, it’s allowed!

If you are doing the preparing, shopping and cooking for the holiday feast, remember that you have the right and the ability to dictate the meal content. Substitute some applesauce instead of the full amount of butter in the cake. Offer a range of your favorite vegetables to accompany the meal. Strain the fat off before mixing the gravy. Determine the ratio of desserts to guests—must it be one pie for every two people?


Be prepared.

Feeling overwhelmed? Preplan as much as you can. Make a shopping list; then send someone else to retrieve the foods. Bake in advance, and then freeze cookies and cakes. Sure, you may end up eating them right from the freezer, but wouldn’t they taste better eaten mindfully at room temperature?

Plan for the holiday eating schedule—be sure to eat breakfast in the morning, rather than letting one meal slide into the next. And don’t even think of restricting early in the day to compensate for potential overeating later. That, my friends, is a recipe for disaster.


Consider your limits.

And do watch your alcohol intake if you are trying to stay in control of your eating. Sure, it might decrease your stress, but it will also decrease your inhibitions around food (and, perhaps around those difficult relatives). That may be fine, if you are comfortable with the outcome. But it seems to me that rarely is the case.

I hope this helps limit the holiday stress.
Do enjoy the holidays, including your favorite foods!

Happy Holidays!



Friday, December 16, 2011

The Gifts You Brought Me: Priceless Progress This Holiday Season

Winter holidays are still several days away, but early gifts of gratitude have already shown up at my office. Yesterday’s were particularly sweet to me. Kay presented me with a lovely handcrafted pair of earrings, sold as a fundraiser for Project Have Hope. (Love that name!) 

Guess who knew there were some yummy cookies to uncover?
But I was even more touched by the additional part of her packaged gift, which Mica (canine to the left) unwrapped for me last night. Kay apparently recalled my familiarity with and love of her favorite cookies—Petite Ecolier. Yes, Kay could openly discuss how many chocolate covered French biscuits she consumes, and the pleasure they bring her. Gone are the cookies eaten in the closet—and the car, and in front of the computer screen.

I earned silver yesterday, but felt like I was the recipient of a gold; I loved the sterling earrings crafted by an Israeli artist that my patient knew I’d appreciate. But the even greater gift was my experience of our session. 171.5 pounds she has lost since we began our work together, from her presenting weight until now. 


No, that was not a typo. She started just below 400 pounds. There was no gastric bypass, in spite of the urging of her doctors. She has needed to decrease her diabetes medications as she has continued to progress. And after years of me patiently wearing her down, she is now exercising regularly. This was the most challenging piece to accomplish. Yes, she bought herself a new bathing suit for her water aerobics class she attends twice weekly. And she has been consistently walking a couple of time per week as well. It was quite the gift to behold all the progress she had made! You can read an old post on her: http://dropitandeat.blogspot.com/2011/02/maggies-152-lbs-weight-lossthis-time.html.

The other gifts were not intentionally timed with the holidays, nor were they intended for my benefit alone. There was Kate’s decision that life is worth fighting for, that her eating disorder needs to leave and that she needs to accept that a higher level of care is not a failure, but a move forward. Termination with some patients was also a gift—no, I wasn’t losing patience with them—it’s just that they were ready to move on—and I was so pleased to watch them fly.

Wishing you a peaceful road ahead.
Emails with thanks and appreciation for this blog arrived throughout the year— comments from Australia and British Columbia to France and Switzerland, from patients and fellow professionals as well as strangers—tales of a post, or a sentence, even, that made a difference, providing a sense of hope that wasn’t there before, a new perspective on their situation, a motivation to reach for something better than they have. Not all were positive and upbeat, that’s for certain. But having someone reach out for help, and appreciate that support I have given, is quite a gift.

These have been the greatest gifts I could ask for.


Coming up: More management strategies for this challenging, food-focused time of year. Look for it within the next couple of days.


Friday, December 9, 2011

Following a Vegan Diet. And, a Gluten Free Diet. And, and, and…



Couldn't Resist This Photo Op In Switzerland!
It’s time for some praise for doctors. Surprised? I know you are used to my airing my complaints here, for inappropriate, unconstructive assumptions some doctors make. And, for their misinformation not infrequently conveyed to patients, when it comes to diet and disease management. Just last week, a patient with type 2 diabetes shared her experience about her follow up MD visit. Jane has been eating well, resulting in a significant and appropriate weight loss. She’s moving more, and watching her carbohydrate intake, improving her post meal blood sugars. But given that her morning numbers remained quite high, in spite of her fabulous lifestyle changes, I encouraged her to address this with her doctor, hoping for a shake up in her diabetes medications.

Can you guess what he told her? 

You guessed it. Just lose weight. Yes, he wanted her to continue to stay with sugars almost 100 points too high, potentially causing damage to her blood vessels and her organs. Perhaps continued weight change will improve her sugars—but that takes time, and with the 50 or so pounds she has already lost, the numbers haven’t changed significantly. But it’s easier to pin the responsibility on the patient to change.

Oops! I was planning on praising a doctor today!

The wisdom of Dr. Mars

His patient was not an obvious referral for nutrition counseling. She did not present with any complaints about her health, and her rudimentary labs did not flag any concerns of disease in the works—normal cholesterol, blood sugar, thyroid, to name few. Other, more detailed nutrient assessment is pending. Her blood pressure is fine, low in fact, with that “healthy runner’s pulse”. And her weight? It had dropped from her usual place many years ago, from the normal range, when she had been diagnosed with cancer, now in remission; but it had increased somewhat since then.

“What brings you here?” I asked, as it was not so clear, at first glance. “Dr. Mars suggested I get in to see you”, she replied.  “His concerns?” I continued. “He’d like you to assess my diet and be sure it’s adequate.” Fair enough, I thought.

At least she's left with these--if they're uncooked!
And here’s what I heard. Di moved from a vegetarian diet to a vegan diet some years ago, presumably to be healthier. She then cut out soy products because of inconclusive evidence of a link between soy and some cancer. Only she did not have the type of cancer that might have even been impacted by soy. She then decided that she should cut out gluten, because she thought she might be allergic. She didn’t notice any change, but had heard (from reliable sources, no doubt) that it helps. So she stuck with it. Rumor had it (Hollywood tabloids, perhaps?) that the raw food diet was a means to extend life and stay fit, so she tacked on those rules too. 

I’m not sure I could have created such a patient from my imagination. The only thing she hadn’t reportedly restricted was fats. But judging by her food selection her intake of fat was quite low, unhealthily low. Oh, how wise of Dr. Mars to send her my way!

My confession

We do the craziest things for our cause.
I get it, at least to some extent. If you’ve been handed a diagnosis for which there is no cure, or one which can easily take your life, you feel quite vulnerable. So anything you can do to potentially help your situation makes perfect sense. And so early in my diagnosis with Multiple Sclerosis I embarked on my own gluten free adventure. Armed with anecdotes spread across the Internet, I was determined to take charge of my condition in any way I could. I knew that the science was sketchy, at best, in its infancy in fact. Much had been written about other auto-immune conditions and the benefits of a gluten free diet, but little to no research existed for MS. I had my MD check my labs, which revealed some abnormal levels—so maybe there was a link, I thought. Celiac experts (those that address the autoimmune disease truly caused by consuming gluten) dismissed these labs as inconclusive, but I was determined.

Three months of strict adherence to a gluten-free diet cured my MS!

Don’t I wish! Rather, meticulously following a gluten-free diet was a constant reminder that I lived with this medical condition; kind of like following a meal plan with an eating disorder. But if it worked, I would follow it forever. Only it didn’t work. Sure, I felt I was taking charge, doing my part to control my disease. But in those three months I had more new lesions on my brain and spinal column than perhaps at any other time in my 9 years with MS.


There’s a point you have to ask yourself “Is this strategy working for me?” Is it really meeting the need I intended it to meet?

 Gluten-free failed. But fundraising and riding with my team of friends and
family (almost half of whom are MDs) has helped me enormously.


Did Di’s strategy improve her health with her myriad of diets rules? Hardly! She now had irregular periods (potentially due to a low percent body fat), and she likely will be experiencing muscle wasting, as her total calories and total protein are insufficient for her need. Osteoporosis or osteopenia , its precursor, is inevitable, with her low calcium intake and vitamin D, and with her questionable estrogen levels, given erratic periods. I could go on listing the pitfalls of her diet, but I think you get the point.

Focusing on her food rules may very well work for Di—on some level. But if she allows herself to be honest, she’ll realize that this is not a healthy diet at all.

And you?

Is it time to reexamine your own patterns of eating or food rules? Are your eating behaviors really working for you? And is it in your hands to change?

I’d love to hear from you.
Thanks for reading and for giving me your invaluable feedback!

Saturday, December 3, 2011

What Your Healthcare Team Needs to Know About Your Non Compliance.

Compliant |kəmˈplīənt|
Adjective
1. inclined to agree with others or obey rules, esp. to an excessive degree; acquiescent : good-humored, eagerly compliant girls. See note at obedient. (From the New Oxford American Dictionary)

A picture of NON-Compliance. Only a biscuit will
motivate him for action.
It’s rare that I have the opportunity to chat with a medical student, a soon to be doctor. But this past weekend I was fortunate. Mike, a bright, articulate, and lovely guy of 28, is nearing the end of his fourth year of his medical education, currently doing his internal medicine rotation. He attends a top medical school in New York City. And you know me. I just had to ask him, this soon to be practicing doctor, a few pressing questions, while strolling along the brownstone lined streets of NYC. Here’s how it went.

LL: “So how much nutrition education do you get throughout your training?”
Mike: “About 5 hours total, in my four years.”
LL: “And what kinds of nutrition topics do you cover?”
Mike: “The greatest focus is on all the vitamins and minerals and their deficiencies—scurvy, beriberi, Wernicke-Korsakoff, to name a few.”
LL: “Wow, so the bulk of your nutrition education is spent studying conditions that we rarely see in our country.” (scurvy is a vitamin C deficiency, beriberi a thiamin deficiency rather uncommon in these parts), with the exception of Wernicke’s which we do see in severe alcoholics (also from a thiamin deficiency).

Further along in our conversation Mike shared his frustrations regarding nutrition-related illness:

“Patients tend to be non-compliant. You know, they don’t do what we tell them, what they need to do to help themselves.”

What does your doctor need to hear from you in
this limited time?
And with that comment, I had to hold back my biting tongue. (He really was a lovely fella, and a friend of my son, so I took a breath and went for the patient response.) Yes, it is frustrating to feel that people could help themselves if only they would follow what you tell them to do, if they would just do it. We discussed the fact that the average length of a typical doctor’s visit is maybe 17 minutes, start to finish; during the length of three songs on your iPod, your doctor needs to assess your medical situation, answer your questions, figure out how best to convey information to you about your condition, educate you and direct you to resources. Sounds easy, no?

Clearly something gets missed in these limited length visits. How can providers expect patients to change when they haven’t even probed to see what obstacles are keeping them stuck?
For better “compliance”, doctors need to better assess patients’ readiness for change. And then provide them with correct information and useful resources to go forward.

Laziness Keeping Her From Exercise?

Maybe there's another reason she (he?) stays where he's at?
And no, I didn't pose them when I too this picture.
You can’t tell someone, like my patient Ellen, who might benefit medically from an increase in physical activity for her blood sugar, cholesterol and blood pressure management, as well as her escalating weight, that she needs to exercise four days per week, 30-40 minutes. Why? Because she associates an increase in heart rate with anxiety, and fears it’ll result in a heart attack. Instead, I had to work on getting her to see that exercise is safe, first and foremost. So I discussed with her doctor getting a stress test done, followed by a doctor’s approval for exercise, to allay her fears. After that, she was able to slowly increase her activity. Now she exercises regularly.

Time To Change The Strategy

 Stubborn and non-compiant--
but who knows what's going on inside his head?
More than one woman I have worked with has shared that her husband has made it clear in no uncertain terms that she shouldn’t be eating what she eats, or weighing the weight she weighs. The result? An “I’ll show you” response—she eats beyond her need, when he’s not around, in part to spite him. Acting like her husband, telling her what to do, judging her by her size, will ensure that her weight continues to climb. Instead, directing such patients to work with a therapist to better communicate with their spouse (and others) and speak up for them selves can help. And enlist their suggestions, their ideas for practical change. That’s a way for providers to successfully problem solve.

And such patients need to be given permission, with practical strategies, to bring food out of the closet. I often recommend that they tell their spouse what to expect—that they will see them eating foods the spouse deems unacceptable for weight management—and they shouldn’t be surprised. And their spouse should withhold comment and judgment, thank you very much. Only then can we expect “compliance”.

Information Can Cause Slips

Health care providers need to check their facts, before being quick to disseminate information. Telling patients “cut out your carbs” is simplistic and unnecessary, including for diabetics. And you can bet it’ll lead to non-compliance. And confusion, as they get bombarded with nutritional misinformation from all ends. It is unrealistic, and not a practical change.

They need to get educated, too, in communicating information with teenage and adult, anorexic girls and young men. Statements like “great job! Your weight’s heading right up there!” or “You need to gain weight or you won’t get your period” can be traumatizing. Or “You’re perfect—don’t gain another pound!” And how many girls couldn’t care less about getting their periods? Telling a 12 year old that not getting a period will lead to osteoporosis? Who cares? They envision old, bent over, great-grandmothers—not something they believe can happen to them in their teen years. But tell them amenorrhea could cause fractures when running or engaging in their favorite sports, requiring them to end participating in sports with their friends—now that may make a difference.

What’s In It For You?

Listening to what patients really do care about, about where their concerns lie, will help motivate change. For some, it’s about hair loss in clumps, or lanugo, hair growth on their arms or face, as their weight has dropped, that concerns them. Or it’s being freezing all the time, as their body temperature has dropped. Or the fear they will not be able to return to soccer, or dance, or field hockey, to name a few.
Sure, doctors and health care providers get frustrated by non-compliance. But our patients are no less frustrated—and they’re angry, and hurt—too. Because they are not understood; because there are good reasons they stay stuck in their unhealthy behaviors. And it is rarely due to ignorance.

Advice For Fellow Healthcare Providers

Compliance shouldn’t be the goal we shoot for. Patients need to be more than puppets nodding and acting according to our commands. (See definition of compliance.) 

They need to be engaged in the process of change, participating in charting their course. We all need supports, guidance, and compassion, not just rules, to begin making change. Oh, and did I mention the need for hope? Certainly, if I don’t believe in my patients, they won’t believe in their own potential for change.

The health system isn’t going to get over-hauled any time soon. Seventeen minutes may seem like a luxury in the future. But if only doctors and other providers would take the time to ask a few key questions. And then? Give up a few minutes of the 17 to truly listen.
Then they can refer to appropriate providers—the nutritionists and therapists experienced in a behavioral approach to change. Only then can they assist their patients in making change, helping us all feel a lot less frustrated.


Sunday, November 27, 2011

Why Bother? Patient Lessons.

Tuesday With Marla

Gotta love her attitude!
Why bother? That’s what I thought. I worked hard on making changes, and in spite of my efforts, here’s the bland response I got from my doctor in this letter: “Your A1c is fine. Your lipids are high. LDL 105, HDL 46, Triglycerides 167. Stay on the statin. Continue to work on your diet and exercise.” If we hadn’t already discussed these results together, you and I, I would have just blown it, food wise.”

What’s this all about, you’re wondering? Let me fill you in. Marla has been working with me for about 8 months. She presented to me with high cholesterol, high blood pressure, and obesity. And her A1c, the blood test that gives a picture of blood sugar control over a three-month period, was just about out of range when she first came to see me. But most distressing to her, was her relationship with food, her struggle with binge eating disorder. Her emotional triggers were real, and life continues to have its share of stressors.

So what happened to Marla?

Here’s the quick summary, based on the concrete facts, the numbers, first. Her A1c dropped into the normal range, several points below where it started. And several points, on the A1c scale, is a pretty huge change. Her ratio of total cholesterol to HDL—the good cholesterol—improved significantly; it is now well within the healthy range, below 4.3. And it started at 6.1. Her good cholesterol is higher than ever, about 40% higher, likely the result of the significant improvement in her activity level. Of course I shared this great news with her at our recent session, expressing how pleased I was that she achieved this dramatic improvement while simultaneously reducing her dose of statins, the cholesterol medication she had been on from the start.

And while her BMI remains high, she is down 43 pounds. And get this—her food record today revealed proudly inclusion of Pay Days, the mini Halloween sized candy bars she gets on sale after Halloween. One or two at snack were consumed when she needed to eat, when she got hungry. And she ate them for many days, I’ll add.
Why so proud to be consuming these chocolate peanut candy bars? I’ll tell you.

Keeping dessert in balance, Marla now can enjoy her favorites.
These, though, are mine-homemade French macarons.
Because, as Marla stated, “Just last year, I thought that once I started I couldn’t stop—because that was what would happen—in the past. I’d find a trail of Pay Day wrappers strewn about my apartment, unaware of just how many I had eaten throughout the evening. Now, I’m not in deprivation mode. And I can record (and acknowledge) that I ate them. And I can eat them in moderation, and enjoy every bite.”

But when Marla saw the doctor’s letter, she had to work hard to remind herself that she really had done well, regardless of how his summary distorted things. “Lipids are high”? They are not only significantly improved, but almost all the values are now in the normal range. “A1c is fine”? How about “Job well done! You are now in the normal range as a result of your hard work! ? Marla had gone from a fatalistic approach about her health—she shared that she never expected she might outlive her relatives, many of whom passed on in their 50s of heart disease. And when she first saw the doctor’s letter she assumed, once again, why bother? I guess I can’t change the situation. She assumed that genetics tell all—her high levels were just meant to be, and there was little she could do about them. But now she knows that is not so.

Why bother?

Even if her levels hadn’t improved (which of course they had), was it really a “why bother” situation? Certainly not! She felt more in control of her food, was able to include whatever she liked now, in reasonable amounts, and was more fit than ever, with her increased activity. She felt physically better having lost weight, and mentally, was in a better place. And she was taking an active role in her health, rather than assume her fate was sealed because of genetics.

And then there was Sarah.

from the MOMA, NYC
Sarah, in her mid twenties, presented yet another “Why bother?” to me last week. (Was it a full moon, or just one of those weeks?) She has been working on recovery from anorexia and bulimia. Medically stable, she has been out of an eating disorder program for several months, since we began our work together.  And she’s doing quite well, I might add. There’s no crisis now, no flames to put out, no imminent need to push her self. Yet she still needs to continue her work to gain weight, to move into an appropriate weight range.

In our last session it struck me (us?)— getting healthier has its risks. It means she can’t blame any failures (such as not getting into grad school, or moving forward in a career, or in life) on her eating disorder. And recovery has another downside. When you peel away the eating disorder—the restrictive eating and thoughts or the binge eating—you are left having to feel. And quite frankly, feeling doesn’t always feel so great.




So why bother?

No, this is not me! But I did capture this amazing sight in Switzerland.
Because once you get to this better place with food and your health, and get support for managing those painful feelings, life is more fulfilling. You can rediscover your passions, and get more out of living. You can feel that what you do in the world makes a difference. And you can be more present to enjoy the people around you whom you care about.

Marla could have accepted her assumptions that there’s nothing she could do to change her course—but she didn’t. And the results, on all levels, speak to the benefit of her bothering.

In Sarah’s case, it’s possible that in spite of her eating disorder recovery, she may not get into the grad school of her choice. But without recovery, it is a guarantee for ultimate failure.

Life’s too short to not live it to the fullest. 

Sunday, November 20, 2011

Taking Charge: Practical Strategies for Enjoying Holiday Eating and the Morning After

Ready to take control?

You, my readers, are a diverse bunch. Some of you are overweight, perhaps higher than your usual and healthy weight. You struggle to have balance in your eating—to eat what you’d like, and to learn to eat just enough. Others maintain their weight in a healthy range, yet grapple with these very same issues. Just because you may look fine, doesn’t mean you’re not challenging yourself to improve your relationship with food. You, too, may be working on legalizing foods, moving from a diet mentality.

Many of you are underweight, as evidenced not only by the scale, but by your body’s function—your low heart rate, body temperature, or hormone levels, resulting from inappropriate weight loss, food restriction or over-exercise. You too may be trying to release yourself from the grips of disordered thoughts and behaviors around food, whether or not it is visible to those around you.

Yet as diverse as you are, it seems most everyone gets challenged around holiday and social eating situations. Social anxiety may add flames to the fire. But I’ll leave that to the therapist bloggers to better address.

Last November, I did a post on recovering after slips, such as after Thanksgiving. Now I’m realizing I’d better address prevention. Perhaps I should have thought of this sooner? It’s not too late! (For those non-US residents, plug in Christmas, Hanukah, Kwanza or any other social eating situations not connected to a holiday celebration—the situation is the same.)

It may seem strange, but regardless of what end of the scale you’re on, or what your personal needs are— weight loss or gain or stabilization—these guidelines apply. Because we all want a sense of control over our situation—to eat what we’d like and eat enough of it—but not too much; to enjoy eating and feel entitled to eat, regardless of our size, in spite of the opinions of others; we’d like to free ourselves, discarding those useless rules around good food/bad food, appropriate times, and inappropriate times to consume food.

So here are my tips:

Maintain normalcy before the gathering.

Don’t skimp on your eating beforehand or you’ll be more vulnerable at the event. All too often I’m told of a client’s attempt to prevent overeating. What do they do? They eat less before the meal out or the function, figuring they’ll save some calories. Then they arrive more vulnerable than anticipated. As a result, their resolve to mindfully select their food, or to pace themselves through the afternoon of eating goes out the window.

The sensory stimulus doesn’t help.  The pleasant aromas and visual displays of appetizers through desserts calls to us. Their strategy backfires, and they feel a sense of hopelessness with getting their control back.

Using your head to maintain the necessary balance
Or like my patient, Shari, you restrict before the event, eat fine or over eat at the event, then restrict again afterwards. Hmm. Does this make sense? Somehow, when you hear it told about Shari, it’s clear how senseless this is. Yet my clients believe that somehow they are different, that the rules don’t apply. They are smart. They get it. I know they do. Yet I frequently have to remind them they are not special; lovely individuals, yes. But not so unique that the system doesn’t apply to them.

Get informed. Ask questions.

"What will you be serving?" "What time will we be eating?" It helps having a sense of what to expect. Going to a friend or family’s home? Ask what you can bring—not if you can bring something. Perhaps you'll contribute something you really enjoy and feel good about eating. A lighter dessert? A favorite vegetable dish? An appetizer you’re comfortable eating?

Pre-plan.

It starts with inquiring about what’s being served. For some, it’s necessary to think through your options in advance. If you are dining out, consider checking the menu online, to be less overwhelmed with the decision making during the gathering. Going to family for a holiday meal? Hmmm, they’re serving 6 different starch choices, including mashed potatoes, stuffing, winter squash, sweet potato casserole, biscuits, and pumpkin bread. Which ones can I get at any time? Which ones are my favorites? Which ones should I just pass on, without regret?

Remember, it’s not your last chance to eat.  So if cranberry sauce is a favorite, plan to buy it and keep some at home. Add it to turkey sandwiches or make a turkey with the fixings, even when it’s not Thanksgiving or Christmas.

You don’t need a dog for a doggie bag. Plan to bring a piece of pie, or a package of leftovers for a later time. Perhaps you’ll get hungry again later that evening. You’ll better appreciate the leftovers when you are less full anyway.

Plate the appys.

Enjoy the appetizers. But know how much you are eating. Select what you’d like, and place them on a plate, together. This allows you to take note of what you are consuming. When we are simply grazing on them, without really seeing or acknowledging them, it is much easier to over eat.

Watch the alcohol.
Painting by Russell D'alessio, Bar Harbor, ME
I hope these women had eaten before their martinis!

Nothing decreases our awareness and inhibitions like alcohol. If you can drink responsibly, that’s fine. Best to delay your drinks until after you’ve had some solid food, though.



Be flexible*.

Maybe you decide you’d like something other than what you intended to eat. Or you ate more than you anticipated, even though you tried to be well prepared. The worst thing you can do is to beat your self up. Best to work on moving on. (Yes, it takes 3,500 surplus calories to gain a single pound.)

We may not be able to control senseless comments from those around us at family and social gatherings. And unless we are hosting, we can’t eliminate temptations. But we can certainly take charge of our own thoughts and actions. And in the worst-case scenario, remember it’s only one meal, or one day. So if you ate more than you needed and are sitting with regret, re-visit that old post on the morning after.

* Did you, like me, wish this subheading was left-justified, instead of over here on the right? It's the start of being flexible!

As always, I'd love to hear your thoughts!


Sunday, November 13, 2011

Healthy Food = A Healthy Diet? Not Necessarily.

My lunch on a hike in Switzerland
Organic, whole grain, natural, unprocessed. These words carry visions of ideal diets, of pure and clean eating, of good health.  US News and World Report’s recent article  summarized the healthiest diets, from The DASH diet at the top of the list to The Paleo near the bottom. A panel of experts reviewed each plan for safety and nutritional value—then ranked the best down to the worst plans for health and weight control.

Here’s a brief summary of a few of their findings—with my interpretation added. You didn’t think I’d let this pass without putting in my two cents, did you?

DASH diet

Never heard of it? Not surprising, unless you, like me, have high blood pressure. DASH, an acronym for Dietary Approaches to Stop Hypertension is shown to be as effective against hypertension as medication, when compared side by side in studies. Its key elements are large quantities of fruits and vegetables, and inclusion of three low fat dairy products daily. It also includes lots of grains, and adequate amounts of lean protein sources. It recommends limiting sodium intake and being physically active as well.

What does this expert think? While it hasn’t normalized my blood pressure, the studies on DASH are quite impressive in demonstrating an improvement in blood pressure. And that’s what it was designed for. And it’s one step you can take to be healthier, if you have high blood pressure. I like its positive focus—on eating more fruits and more vegetables than most individuals consume, and on inclusion of three low fat dairy servings daily. Watching sodium generally necessitates eating less processed foods, which may lead to greater fullness—think apple versus juice.

Paleo diet

The theory, according to US News, is as follows:

Our highly processed, carb-obsessed eating pattern is the culprit behind many of our biggest health ills, so why not go back—way back—to the Paleolithic period of more than 10,000 years ago, when our diet wasn’t full of junk food and pasta? Paleo advocates say we should eat the way we ate when we were hunting and gathering: animal protein and plants.

The diet includes meat, fish, and other protein sources, as well as fruits and veggies, but omits dairy, grains and starchy vegetables, and several oils. Yes, even protein-rich, high fiber, satisfying legumes (think beans and lentils) are out of the question. As are root vegetables, such as sweet potato. (Imagine Thanksgiving at the Paleo family’s home!) Apparently these are omitted because they needed to be cooked. And say goodbye not only to milk, but also to those gut-beneficial probiotics we consume from yogurts with active culture. Never mind the lack of evidence that supports eliminating these foods.

If I have to give something up, there darn well better be a good reason for it. Unless there were some life altering evidence in favor of a Paleo, I say let’s be thankful we’ve evolved since then. And how fortunate we are to be able to consume legumes and grains—those carbohydrate rich foods, full of minerals and energy, as well as rich in fiber—given that we can cook them. Most of you, I suspect have a stovetop?

If you are not living in a year-round warm climate—rich in sunshine used to produce vitamin D, or you choose to prevent skin cancer by using sunscreen—you’ll be missing out on the foods necessary to obtain all the Vitamin D that you need following the Paleo diet. By the way, why use a Paleolithic period diet as some ideal, anyway? Their lifestyle was a bit different, I believe (I haven’t had to chase my dinner), and our lifespan has only increased over the years.

As for Atkins?

The lack of carbohydrate through many stages of this diet, and the saturated fat-rich intake flies in the face of all that we know about disease prevention. Review the 2010 Dietary Guidelines For Americans for an evidence-based review of these recommendations. Is anyone really taking this diet seriously anymore?

And Ornish?


Generally pretty extreme in it’s limitation of fats, which research confirms is not the cause of us getting fat; weight loss at the 12-month mark was no greater with a low fat diet, compared with many other popular diets. And any differences in weight loss between various diets (containing the same calorie level) was obliterated at the later follow up date. No, fats don’t make you fat. And a super low fat diet does not appear to be necessary to improve your lipid profile; very low fat diets may increase triglyceride level, an independent risk factor for heart disease. In the Ornish diet, meat, poultry and fish are not recommended, as well as all oils, nuts, seeds, and refined carbohydrate. It has its merits for reversing heart disease, but his studies showing this reversal focused not solely on dietary changes, but included a comprehensive stress reduction and exercise component.

Mediterranean Diet

My only beef with it is not its lack of meat, but its limited dairy. There’s no support for restricting dairy, particularly low fat varieties, for good health and weight management. I do like their inclusion of moderate amounts of wine, with meals, for those who are able to limit their alcohol. This diet is much higher in fats and carbohydrate than most, but includes, for the most part, less processed varieties. That said, they do not urge extremes, such as no bread or white potatoes.


The U Diet: The best diet you've never heard of

What was unfortunately left off the list of healthy diets was the U diet. Missing is consideration for the individual, because what’s healthy for one person is not necessarily healthy for another. Eating healthy, for many of you, should mean not trying to beat the system and eat less (like the Volumetrics Diet, for instance). Even those 2010 Guidelines for Americans act as if we are all obese and unhealthy and needing to eat less. It’s a challenge, for sure, when the rest of the universe is struggling to drop a few pounds or kilos and you are working, somewhat reluctantly, to gain them, or even to maintain them!



The U diet is truly the answer. It means, first and foremost, including an appropriate intake of calories. Ideally, if you are healthy enough to do so, this is done through better self-regulating (read the 100 or so posts in which I’ve addressed this already. Then re-read them!). It involves more mindful eating, and distinguishing hunger from other eating triggers. You know what I mean. 


But it also means releasing yourself from the rules which prevent you from eating when you are hungry, regardless of whether its only been two hours, or if it’s after 8 PM.

As I’ve mentioned previously, for many of my readers it requires the “just do it approach”—eating in spite of not thinking or feeling you need to eat.  It may defy all the healthy recommendations you’ve read above. Yes, you may be among those that need to decrease your vegetable intake, if they are displacing the calories and nutrients your body desperately needs to function.

Let's take Brian, whose diet was chock full of such wholesome ingredients, as recommended by DASH, Volumetrics, Mediterranean, and some dieticians' model diet.

Breakfast
Old Fashioned rolled oats with soy milk
Snacks
Fresh fruits and vegetables, both orange and green ones

Lunch
Brown rice and veggies

Dinner
Beans and a vegetable soup

Pretty good? Not at all. At 6'1" Brian struggles to function. His determination to select what he considers healthy foods has made him anything but healthy. His energy level is low, as is his testosterone level, impacting a range of quality of life activities. Let's just say, it impacts more than just the frequency of his shaving. His weight, while I will omit mention of numbers, is unhealthily low.

Or let me tell you about Sarah's recent diet. Her move away from "junk" food to a more wholesome diet landed her with a low heart rate and a plummeting weight, now below the 5th percentile. Never one to struggle with her weight in either direction, she now teeters on the need for a hospitalization. Her diet is low sodium, making it more challenging to keep her blood pressure in a healthy range given her unhealthy weight, contributing to her lightheadedness with posture change, from lying, to sitting, to standing.

And then there was Amy, who never intended to lose weight. Really. She gradually moved toward less processed foods, leaving her favorite items behind. Who needs Pop Tarts anyway? Her biggest concern, besides her hair loss, is that she is constantly freezing, even with the record warm temperatures we have had this fall in New England. This is what is motivating her to break from her "healthy" diet.

Diane was also concerned that her daughter wasn't eating healthy enough. Review of her intake revealed the following—she consumed a variety of foods, but would benefit from additional sources of dairy or an alternative. She included meals, but was somewhat picky about what she liked to eat -- pasta was high on her list, as well as several other choices. And for snacks, she responded to her hunger with what appeared to be reasonable quantities of items like Chips Ahoy cookies -- or fruit, or cereal.  She certainly could use to increase her intake of fruit or vegetables, for the variety of nutrients they provide, and for the fiber. But she eats enough to maintain a healthy weight with healthy body function. Her diet supports her need for energy, for fuel, to engage in the activities she enjoys.

Ahh, all butter pump cookies!
The Chips Ahoy? Those processed, refined carbohydrate and sugar containing cookies fit just fine, in the context of her diet. As long as she is getting all the nutrients she needs from a variety of foods, and she needed the calories from the amount of food she consumed, if Chips Ahoy was here snack of choice, why should I try to make it "healthier"?

Healthy eating, to me, is not just about healthy foods. It is about getting enough of what you need--enough calories--from protein, fat and carbohydrate to fuel your body and allow for repair and normal function. It includes a range of vitamins and minerals, as well as all the nutrients, such as phytochemicals, that we are learning contribute to disease prevention (think about selecting colors -- deep orange and yellows as well as deep green, and reds and blues in vegetables and fruits). It includes whole grains, and refined, low fiber foods as well (think French bread or my much photographed challah—white flour and delicious!)—because in our world we also need to balance our need for convenience with our busy lives. And, our interest in eating foods we enjoy.

Follow the U diet, and you, too will rest
peacefully!
Besides needing to meet our physical need, we cannot dismiss food's other benefits. There's the pleasure factor, the enjoyment of the taste and texture, the sensory experience of eating. I'm not saying we should simply eat for pleasure. Rather, that we need to consider these aspects of eating when we are hungry and seeking food. What do we feel like eating? What would we enjoy eating? Not simply what should we be choosing.


Consider the U diet. It may not be a best seller, but it’s a sensible, and healthy diet for your body and your mind.