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

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

No wonder meal planning is a challenge.

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

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

Why can’t I decide what to eat?

If you're like Kristen, you get so over-focused on what you shouldn't eat that you're challenged to figure out what to eat.  Your endless food rules about nutrition, weight and health leave few foods to eat—and enjoy. 

I've lost count of how many patients came into my office these last weeks, stating: "I have no idea what to eat anymore. I just can't decide." These are patients of all sizes and conditions—patients with anorexia, and those with binge eating disorder and bulimia; and those struggling with their climbing weight and obesity in spite of their attempts to eat healthy. And they’re all ruled by unnecessary food rules.

Wrong, wrong, wrong about fats!

Like Kristen you too may be fat phobic, in spite of the updated newest guidelines for Americans 2015, which have removed the notion that total fat should be avoided. Got that? There is no evidence to support a recommendation that total fat should be restricted—neither for weight management nor for health and disease prevention. 

Really? How can this be?

At the 2015 Scientific Sessions of the American Diabetes Association (ADA) there was a wealth of research showing that diets rich in fats from plants sources—with nutrients like mono unsaturated fats (think avocado, peanuts and olive oil)—and in omega 3s (think salmon, sword and tuna in addition to walnuts and flax) help reduce abdominal fat distribution which is the greater health concern than obesity.

And, wrong about carbs and weight gain!

Also at the ADA, extensive research was presented concluding that macronutrients—the protein, fat and carbohydrate balance of your diet—ultimately have no impact on your weight. That's right. Numerous large studies including a well-done Harvard study confirm this.

I know, I know, it’s hard to believe when you’ve already been sucked into the misinformation of carb and sugar toxic diets and fat phobia.

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

Remember when you used to simply eat?

Move from micromanaging your foods.

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

Consider OJ.

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

Must our pasta be whole wheat and protein fortified or be banned from our diet? What if you started with white pasta—yup, no fiber, all carbs, delicious pasta? You don't need to have the whole 16 oz. of it. By itself it's hardly a balanced meal. But surely you can find a solution to that, right?

Yes, you can add vegetables—for vitamins, for volume and texture, for fiber and satiety. Feel the need for protein at that meal? Add a glass of milk, some cheese, some shrimp or chicken or smoked salmon.  See where I’m going? 

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

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

Now that’s healthy eating.

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

Why I’m worrying about Vyvanse and Binge Eating Disorder

Seeming quick fixes can be so tempting.

This week’s inbox held the following message from an old patient:

“I was watching Good Morning America and they had Monica Seles on, admitting she's suffered from binge eating disorder (BED). They announced a medication they are now using to treat BED, Vyvanse, also used for ADHD. I looked it up and side effects include weight loss. Have you ever recommended this drug for BED? Do you feel it is effective for BED? Can people with BED take this med to lose weight? Do they think if you have BED you must be overweight and this medication can cause weight loss? Which would perhaps (in their minds) solve the bingeing?

That small ED voice that lurks deep from within is screaming 'get me that drug! Get me that drug!' so I can lose weight. WTH?!"

I’m glad she was brave enough to share what she was wondering, as I’m sure she’s not alone in her curiosity. Aren’t you wondering what this means for you?

Let's start by clarifying a few things about binge eating disorder. Most notable about BED is the recurring episodes of binge eating, feeling out of control while binging, and feeling guilt and shame afterward. People of all sizes live with BED, and the experience of a binge may vary. You might eat large amounts of one item—such as a whole package of cookies—or large amounts from a combination of foods. For some, even eating a single bite beyond what they intended may feel like a binge.

There's a way off the roller coaster--appropriately
named the Cyclone.

The common features among sufferers, though, is the guilt, shame and lack of control accompanying the eating. According to the Binge Eating Disorder Association,  "Binge Eating Disorder (BED) is the most common eating disorder in the United States. An estimated 3.5% of women, 2% of men, and 30% to 40% of those seeking weight loss treatments can be clinically diagnosed with binge eating disorder. The disorder impacts people of all races, levels of education and income — including adults, children and adolescents."

Given the shame associated with BED, however, there are likely many more living with the condition than we know.

Medication to the rescue?

Two recent studies were done using Vyvanse—a stimulant used to treat ADHD—for the treatment of moderate to severe binge eating disorder. They were well-done studies— randomized, double-blind and placebo-controlled—with promising outcomes. 

In one study, participants who binged three or more times per week were treated with either a placebo—a dummy pill—or 30, 50 or 70 mgs/day. Researchers saw a significantly better response to the 50 and 70 mgs/day doses compared to placebo in a study of over 250 subjects with a roughly equal number of controls. Improvements included reduction in binge frequency/week, a higher percent of subjects binge free for 4 weeks, and a change from baseline in the Yale-Brown Obsessive Compulsive Scale Modified for Binge Eating—compared to placebo treatment.

Notable, however were a couple of other outcomes. The placebo group also improved, by 21.3 percent (versus 42% in the 50 mgs/day and 50% in the 70 mgs/day treated groups). Meaning, the belief that taking something could help your binge eating was enough to improve binge frequency.

And then there were the side effects. More than 5% of those treated with Vyvanse reported symptoms including “dry mouth, insomnia, headache, decreased appetite, nausea, irritability, heart rate increased, anxiety, feeling jittery, constipation, hyperhidrosis [excessive sweating].” Twelve patients (5%) on Vyvanse reported treatment-related adverse events that led them to stop the study; 5 patients in the placebo-treated group had such negative effects. 

And then there’s this: “CNS stimulants (amphetamines and methylphenidate-containing products) have a high potential for abuse and dependence.” 

If you struggle with Binge Eating Disorder and are tempted by the positive research results, consider the following before you request a prescription. While medications might improve binge eating, so does addressing some underlying eating patterns and thoughts—without the risks of medication. In fact, since the placebo also improved binge frequency by over 21%, it suggests that the power of believing you could change—with some help—is quite strong with BED.

Yes, there's hope without meds for BED!

Need I say more? http://www.annetaintor.com/

Do any of the following scenarios apply to you? If so, medications for BED may be unnecessary.

1. You restrict your calories throughout the day, trying to be “good”. You deny your body the fuel it needs and by later in the day—often late afternoon or at night—you start eating, intending to eat in control. But then it feels like the flood gates open and you just can’t stop. Perhaps you feel like you’ve already blown it, so feeling defeated, you decide to continue to binge. You’re determined to get back on track tomorrow—with restricting. And so the cycle continues.
2. You eat enough calories throughout the day, but your food choices are very limited—including only foods you "should" be eating based on rules you follow; they may be only high protein, or unprocessed or not very palatable. They are foods that you’re okay with, but that don’t necessarily give you much pleasure. Then, when at a friend’s or out to eat and you eat something to appear ‘normal’ or because you really want it, you have serious regret. Later you continue eating because you’ve already "ruined it", but are determined to get back to your very restrictive, healthy food choices.
3. You truly get enough to eat—enough calories and enough of foods you really enjoy. But most of your eating is quite mindless—you eat standing up in the kitchen, while multitasking—while driving, on the computer or on the phone. So you never truly feel satisfied. And it’s worse when food is kept in sight.
4. You eat enough, you get what you want to eat, AND you pay attention to eat mindfully. But when stress if high, or you struggle with an emotion that’s hard to sit with, your knee-jerk reaction is to reach for food for comfort or to numb out. You may even be completely aware of what you’re doing, but the pull is so strong, because in the short run, it helps. But later, you are left with regret.

If any of the above statements apply, then working with an eating disorder dietitian—together with a therapist can really help. Cognitive Behavioral Therapy (CBT) is a valuable, well-studied treatment for BED, and you can purchase self-help workbooks specifically for this condition as well. 

Learn to normalize  your eating!

Yes, binge eating can be resolved without medication. But it requires dropping the diet and rigidity around eating. Really, dieting simply isn't helping.

For those with ADHD who also binge eat, the medication may be helpful to manage impulsivity—which can lead to binge eating. Delayed gratification—redirecting and waiting to notice fullness—can be too challenging, as is moving away from multitasking.

But using Vyvanse is not without consequences. Decreased appetite may sound appealing but if you don’t know when you’re hungry, it's hard to trust when and how much to eat — making intuitive eating impossible. It may contribute to inadequate intake and food restriction—something those struggling with binge eating may already struggle with. 

Do we need to swap one problem with another?

Further, will doctors inappropriately start prescribing Vyvanse for those who are overweight but not living with moderate to severe BED? Will prescribing seem like the medical quick fix, while failing to address restrictive eating, or deprivation or over-exercising that truly need treatment? 

So, dear readers, please don’t be tempted. But don’t give up hope. Seek out providers that work with binge eating disorder patients because it is in your hands to change.

Other related links you might find helpful:

http://dropitandeat.blogspot.com/2013/05/name-calling-has-its-place-bed-is-now.html

http://dropitandeat.blogspot.com/2013/03/weight-loss-and-recoverycan-they.html

http://dropitandeat.blogspot.com/2013/04/intuitive-eating-is-not-for-youmaybe.html

http://dropitandeat.blogspot.com/2013/03/heres-to-speedy-recovery-maybe-not.html

http://dropitandeat.blogspot.com/2013/04/eating-disorder-recovery-reflections.html

http://dropitandeat.blogspot.com/2012/08/do-or-do-not-there-is-no-try-think.html



http://dropitandeat.blogspot.com/2012/07/forgetting-to-remember-key-obstacle-to.html

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

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

But consider this:

No, avoidance isn't the answer.

• Is it really recovery when the only way you feel in control is to fill your days with so much activity (no, not even physical activity) that you don't get to sit with your feelings? You work long hours waitressing, take on extra shifts or extend your work hours only to avoid being with yourself. You struggle to allow yourself to feel hungry—fearing you're not trustworthy to respond correctly. You equally fear fullness, that satisfying feeling of truly getting enough. Would you allow your best friend to carry on this way?

• Is it really recovery when you stop binging, only to restrict your food intake? You stick around family or friends because you know you'd never binge in their presence, but you also struggle to eat enough when they're around—and even when they’re not. If your child see-sawed between binge eating and restricting her food intake, would you say “that's just fine”?

It doesn't have to be so scary.

• Is it truly changing your relationship with food when your solution for managing chocolate cake—or your favorite flavor ice cream or bread or peanut butter—is to simply never have it around? You forbid yourself access—just for now, until you meet your weight goal, or maybe believing you’ll resist these for the rest of your life. Would you suggest this to your parent, or would you hope that life could be much better for them?

• Are you really recovering when the only way to nourish yourself (yes, I know some of you struggle with this loaded expression which implies self care in its fullest sense) is by keeping everything the same, limiting your food choices to just a few "safe" foods? Or, by weighing and measuring all of your food? No, not just for now, but forever? What would you say to your partner if he or she kept to the same restricted allowance, an even number of items to be comfortably ritually consumed, day after day after day?

Time to start living again.

• How normal is your eating if you rely on counting your calories, or your points a la weight watchers? Or if you can't release yourself from exercising when your intake exceeds your ideal or your self-prescribed amount?

Can you truly recover? Absolutely!

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

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

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

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

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

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

Oh, and please share your thoughts with us!

Thanks.

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?

More on this topic:

• http://dropitandeat.blogspot.com/2011/04/slave-to-diet-deprivation.html
• http://dropitandeat.blogspot.com/2011/04/over-30-or-40-and-struggling-youre-not.html
• http://dropitandeat.blogspot.com/2012/04/0-false-18-pt-18-pt-0-0-false-false.html
• http://dropitandeat.blogspot.com/2012/03/youre-invited-to-celebrate.html

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.