Monday, February 28, 2011

Who or What Decides How Much You Eat? Taking Back Control of Your Eating.

Last weekend I attended a diabetes conference in NYC (Yes, that explains the delayed post!). And although most of you don't have diabetes, there's so much valuable info to share with you.

First, I learned these experts know nothing about the feeding needs of the sedentary. Yes, sedentary program attendees, myself included, get hungry while simply sitting in a chair for a span of many hours. So with breakfast at 7:45, I was ravenous by the 10:15 coffee break. Now usually, when we say coffee break, we mean something more than simply a caffeinated beverage. Like, maybe we’d expect a mini pastry or muffin, or some fruit? Perhaps the Diabetes Association was using us like lab animals, exploring the impact of low blood sugar on us.

Yes, these are them! My sustenance 'til break time.
In any case, I was shocked, and unprepared, for the absence of adequate, calorie-containing snacks to accompany my coffee. And so I relied on the tiny hard candies to get me through until lunch. How ironic. My point? Just because someone else thinks it's okay to not stop and eat between meals, doesn't mean you have to go along with the plan!

Similarly, just because someone else tells you how much you should eat, doesn’t mean that’s right for you. What do I mean? Just because Quaker oats now says that the serving size is either ½ cup dry oats or ¾ cup for their “heart healthy portion” doesn’t mean that that is right for you. Several years ago, Quaker increased their portion from 1/3 cup dry oats, 2/3 cup cooked cereal. Maybe that amount worked just fine. Just because they’ve adjusted upwards doesn’t mean you have to!

Amazing sandwich from Eataly, NYC which I ate too
much of, having not had an adequate snack at break.
Have you ordered a sandwich out lately? Just half of many sandwiches (take Panera, for instance) more closely resemble a full sandwich most of us would prep at home. And eating only half of most burritos filled with rice and beans and guacamole would likely satisfy—except that once we’ve unwrapped it, we’re doomed to finish it.
And if your spouse or mother-in-law usually plates your food, take charge and plate your own food! Then you can’t blame anyone else for how much you’re eating.

Because we eat what’s put in front of us, without regard to how full we are in the moment, and without delaying to see if we really needed the full amount.

Brian Wansink, PhD, presented a fascinating session on his research findings at this conference (see for more info). This creative researcher developed a strategy to evaluate what factors regulate our food intake, telling us when we’ve had enough. He cleverly designed a feeding study where half the participants were served a bottomless bowl of soup. Yes, the soup was secretly pumped into their 22 oz. bowl, keeping it filled. And what did he find? That people just kept on eating! They ate 73% more soup than those with a finite portion. Yet they didn’t think they had eaten more.

He also interviewed Americans in Chicago, and Parisians, about when they know they’ve eaten enough. Parisians reportedly stopped when they felt full, and when their food no longer tasted good. The Chicagoans, however, made no reference to physical sensations, stating they stopped when their plate was empty, or when their TV show was over. Maybe that’s the answer to the French Paradox. They enjoy their food, including rich pastries and processed breads, but they stop when they’ve had enough.

It’s not that hunger sensations can’t work for us. It’s just that we don’t tend to give them a chance. Remember the titration example? (see ) We don’t allow our bodies enough time to take note and acknowledge fullness. Instead, we eat mindlessly, quickly, consuming more calories than we need before putting on the brakes. Then we blame it on the carbs, or the fats, setting rigid rules about what’s acceptable to eat.

The solution? Take charge of your environment, and of your body’s signals. Even if you need to gain weight, you’ll feel better if you are aware of what you eat. It’s not enough to gain weight, but to learn to regulate a healthy weight.

First, find your voice, and negotiate change, when necessary. If you’re out with others and feel hungry, eat a snack you’ve brought or stop for something. Yes, even if you’re the only one who needs to.

Plate your own food, and take responsibility for your own eating. If you're struggling with being overweight, start with a smaller portion than usual, giving yourself permission to have more after 45-60 minutes—if you’re hungry. If you are struggling to gain weight, consider having your grains on a separate plate, which some find less overwhelming.

Use a smaller plate. The size of bowls, glasses, plates, popcorn containers dictate how much we end up eating. Such a simple trick really works! And Wansink and others have the study results to prove it.

Eating out? Have them cut your sandwich or wrap in half, and package each half separately. If you need the second half later, it’s yours to eat then—if you need it! That’s where listening to your signals comes into play.

Limit eating to the kitchen or dining room. Then leave that room and use distraction to avoid the temptation to mindlessly eat.

Control your surroundings. Keep food off the kitchen counters. And keep fruits and vegetables in glass bowls in the fridge where you’ll see them and think to eat them.

And remember. Slips happen! This approach may be new to you, and other factors besides your awareness may impact your eating. Address your stressors and boredom, if they trigger you to overeat.

And set realistic goals. Work on one change at a time, before setting another goal.

As always, I look forward to hearing what you think!

Monday, February 21, 2011

Calories Count. But I Prefer Not To.

A Balanced View On Calories and Weight.

It’s 11:20 AM. Breakfast was only 2 ½ hours ago, yet I’m hungry. So before writing this post, I march myself up to the kitchen and heat up a brioche, a flaky, buttery, mushroom-filled leftover deep in my freezer. There was no label, no caloric info on this bakery item to guide me regarding portion. And I had the whole thing. And it was delicious. My only regret? I didn’t think to photograph it!

I had just read Ashley’s post at Nourishing the Soul entitled The Great Calorie Debate, including the many reader comments. And struggling to not hoard the space allotted on her comment page, I decided I needed to give this matter my full response.

The comment I did post stated that this, like most subjects, is not such a black and white issue. And if you’ve been reading my blog for a while, you’d know that calorie counting is not my mode of managing weight. Rather than reiterating that viewpoint, I’ll direct you to past posts, focusing on the need for using internal cues, such as hunger and fullness, as distinguished from thoughts (including numbers, shoulds, food rules) and emotional triggers. These also emphasize that weight regulation does come down to calories. But how we regulate them is where some of us may differ.

But here’s the other side of the coin, so to speak. No doubt, calorie counting provides a safety net, an insurance of sorts. Trusting a plan’s calorie level can help individuals on both sides of the scale. If you're a restrictive eater, having a reality check about just how much you are falling short calorie-wise, could be quite useful. It might help to understand why you are experiencing unpleasant symptoms, and provide a template to work toward meeting.
One of my favorites for ice cream at a fraction of the
saturated fat and calories compared to premium ice creams!

Or like Robin, you might be frustrated that you do everything right—you exercise, choose healthy foods, and only eat half your meals when dining out. Yet your weight has been climbing out of range steadily over the past decades. For you, realizing that the 1 ½ cups of Ben & Jerry’s Chunky Monkey provides more than half the calories you likely need for weight loss, if you are less than 5’7” or less than super active. Sometimes that reality checking is quite valuable.

Last weekend while I was out, I stopped at a restaurant for lunch. Fresh City is a regional place, New England based with the motto: “Bold and original creations you can feel good about…” And I must admit, the food quality and selection was quite good. Yet approaching the counter, glancing up at the menu board I was alarmed. It was my first time being confronted with the calorie value of every menu item.

And I felt very conflicted. I certainly knew I was only going to order foods I enjoy, that much was certain. But how did I feel about the regular wrap being, if I recall correctly,160 calories greater than the low carb wrap option? Or the fact that for those little ones 10 and under, a PB and J contained 777 calories? Unless they are doing early Olympic training, that’s an exorbitant amount for a kid’s lunch, particularly once you add in a beverage to go with!

Well, for the record, I ordered the regular wrap (any surprises there?) and my college age kids couldn’t have chosen the peanut butter and jelly anyway (although the caloric value would’ve been more appropriate for them than the targeted customer)! God knows how large their bread is or how much PB they throw on the sandwich! I could tell you it did make my husband ask about his homemade PB sandwiches (which are a little more than half the calories of those designed for the under 10 crowd.)

So here’s the thing. Most individuals who have not abused their bodies with diets and unhealthy thoughts and rules (yes, that may just leave children and a few select others!) will eat part of the sandwich, regardless of it’s calorie level, and stop when they’ve had enough. And if, perhaps, they ate mindlessly, leading to consuming more than they really needed, then they would feel quite full. 

And so, if they listened to their hunger, they wouldn’t be eating until some time later. Maybe they wouldn’t end up needing a snack later—but maybe they would. The point? Even if you didn’t know how high the calories were, if you just listened to your body, and ate mindfully and trusted, you’d be just fine. (Unless, of course, the what the what the heck effect takes over and your dieter’s thoughts convince you that all is already lost and you may as well keep going.

If you’re going to look at calories, be certain to not set an upper limit. Calorie counting is not a perfect science. For any number of reasons, you may get hungry, even if you ate all the calories you think you're entitled to. Then what?! What’s most important is that you learn to honor your hunger. See

It’s 12:55 and I’m not yet ready for lunch. That rich and buttery brioche is still digesting. Lunch just may not happen for awhile. But I think I’ll bring a snack with me when I head out—just in case I get hungry! 
No regrets about the pastry, or about not knowing the calorie content. Sometimes, you just need to trust your body.
BTW, as this is National Eating Disorders Awareness Week, please share this blog with 2-3 friends or family members who might benefit! Thanks!

Friday, February 18, 2011

Maggie’s 152 lb. Weight Loss—This Time, It’s Not Disordered

Eating Disorder Recovery is More than Achieving a Healthy Weight

At the MFA, Boston, MA
Just this Thursday yet another patient shared her beliefs, her fears about recovery. “If I’m at a normal weight then I won’t need to come in. And everyone will think I’m fine”, she stated. And that was one roadblock to her recovery. Wearing her eating disorder, just like, for a cutter, I suspect, wearing short sleeves, is a way of expressing that there’s a problem. It appears to be a way of passively asking for help, when words fall short. 

Some have been surprised when I described them as still having an eating disorder, complete with thoughts of restriction, denial of hunger, and food and weight preoccupation, in spite of having restored their weight.

A significant drop in weight could be a red flag for an eating disorder, or can be the result of healthy measures, in spite of an eating disorder history. And a normal weight can disguise the pain of your struggling with an eating disorder as well. All of the above apply to Maggie.

You’d think dropping 152 pounds would be a major accomplishment for someone close to 400 pounds. And it is, especially at the age of 67. But the more successful part of this story is the move away from reliance on eating disorder thoughts and behaviors, on both sides of the weight spectrum.

Also at the MFA, Boston
Maggie, at 130 pounds and 5’8” saw herself as a “big fat slob”. A low weight for her height by any medical standards, she was obese by her own. She reports never really feeling good about herself, and by her early 20’s had met criteria for anorexia, plummeting to 117 pounds with restrictive intake and bulimic exercise levels. By that I mean exercising excessively, typically to compensate for eating, in an obsessive way.

Like many I see, a motivation to conceive helped enable her to gain enough for normal menses to resume, and ultimately to carry and deliver a healthy daughter. She managed to maintain a healthy weight, although not a healthy relationship with food and her running shoes. And after some time, triggered by a traumatic event, Maggie’s eating disorder turned to binge eating, with a focus on night eating. (Let me assure you that with support from an eating disorder team, recovery from anorexia does not have to result in binge eating and subsequent obesity! But Maggie had not yet sought help.)

Fast forward to the summer of 2002, when at 388 lbs. Maggie presented to see me. Her goal? To lose weight and recover from her many years living with an unhealthy relationship with food. Basically, to learn how to eat and to listen to her body—something she had never really done.

Maggie still comes to see me, every 4-6 weeks. (She has also worked with a therapist, at my recommendation, but they have finished their work together.) Yes, it’s been a very long road, but her progress has been tremendous. It’s quite impressive that she is down 152 lbs. so far. But more impressive, is that it has been years since she has used behaviors to manage her eating and her weight. 
True, there have been slips where I have had to play the “tiger mom” role, insisting that she increase her food intake, when weight loss was getting a bit too rapid. But she heeded my firm warning, and stayed on course. 

And there were certainly frustrations, like when she went to see her primary care physician recently. In reviewing her history, the doctor asked what her weight had been before we began our work together. And when Maggie, somewhat shamefully, admitted it was 388 lbs., the doctor laughed and told her she had to be wrong, dismissing Maggie as exaggerating her weight loss. Could you imagine! This very same visit, the doctor denied her a referral for a therapeutic water program that I requested, to enable her to move more. Because after so many years, no matter how much weight she lost, her knees weren’t going to fix themselves and allow her to start walking. To her credit, the incredible anger and frustration she felt was verbalized, instead of buried with pastries.

Over these years of working together, Maggie has changed the rules. She allows herself to eat later at night—if she’s hungry, and she chooses foods she truly enjoys—but eats them mindfully. Sometimes I find her counting her carbs, but generally only when she’s concerned about her blood sugars, as she was diagnosed with Type 2 Diabetes several years ago.

Perhaps her next challenge will be learning to manage activity—after she has her knees replaced. And for the record, she also followed my most recent advice—she switched to a lovely new doctor, who gladly issued the prescription for the water exercise program!

Tuesday, February 15, 2011

Where BMI Goes Wrong. Lessons From Cupid.

Yesterday was Valentine’s Day and no, I’m not going to flash more food porn involving chocolates. But with Cupid hovering around lately, I couldn’t help but address the subject of BMI, Body Mass Index.

What if Cupid and his parents showed up in my office concerned about obesity, what would I say? Let’s assume for a moment, from the various images of him these days that his BMI was in fact high. For the record, BMI is simply a calculation of weight divided by height squared, used as a marker for obesity. It is not, as you have been lead to believe, a measure of body fatness, or percent body fat.

If historically, as evidenced by Hallmark’s greeting cards, Cupid has always been husky from his youngest years, here’s what I’d say. Assuming he has paralleled the BMI chart, he is gaining as much annually as any other normal healthy child. It’s just that he started larger, simply genetics, most likely. I would still explore his intake and eating behaviors, recommending modifications to ensure health and prevent disease (just as I would do if an average weight individual presented for, let’s say, food allergies). But if all looked well, I would not create a problem where there was none.

If, however, I discovered he was hoarding the chocolates he planned to deliver, binge eating or emotionally overeating, perhaps because of unrequited love, these patterns would need to be addressed—with me, and with a therapist.

Like chocolates, we come in all shapes and sizes. And if your size, like Cupid’s, has always leaned on the larger end of the spectrum, it is likely that is a healthy, and normal place—for you. If, however, you have never listened to your hunger and fullness, tending to regularly use food for comfort or to manage stress and emotions, there’s room for changing your relationship with food, and as a result, your weight.

Maybe as an adult your BMI is out of range, placing you in the “obese” category. That puts you in good company, with top paid professional athletes such as Vince Wilfork and Charles Barkley. BMI is hardly the best way to gauge your size, or your risk of disease. Many with high BMI’s are quite healthy and fit, often at the top of their game. BMI may be high simply from a high muscle mass. Remember, body mass index does not distinguish where that mass comes from—muscle or fat (or bone, for that matter).

Years ago a woman who did body building recreationally came in for assistance with weight loss. It was winter, and quite frankly, visually I could never have guessed what her risk was. By the charts, she was obese, with a high weight for her height. But when I assessed her eating, I could only conclude that she wasn’t eating enough, regardless of her weight concerns. Weeks later, following a half marathon, she reported that she was hospitalized with internal bleeding. Apparently, her percent body fat was so low that there was damage to her internal organs, resulting in the bleed. Yes, body fat does have a function, and cushioning our internal organs is just one example.

But if your weight has been climbing out of a healthy range, and you have not dramatically increased your muscle mass, it may be time to take a closer look—at your activity as well as your food intake and eating behaviors.

And we should be most focused on an individual’s pattern, as opposed to their absolute weight or BMI. I had a teen patient not long ago who presented at the 50th percentile BMI for age. Great, no? His doctor thought so, and was quite pleased with his healthy place on the chart. But a look at his BMI chart revealed that he had plummeted in a very short period, from a high BMI to “normal”. Unfortunately, this drop resulted from anything but normal thoughts and behaviors around food, but rather the consequence of a full-blown anorexia. And reinforcing how “healthy” his recent BMI was only added flames to the fire.

As for the adult Cupid, waist circumference, or waist to hip ratio, would likely tell me more, suggestive of abdominal fat, and associated with chronic diseases including Type 2 diabetes. A waist circumference above 35 inches (women) and 40 inches (men) it is considered a predictor of increased risk. The waist-to-hip ratio—literally, your waist measurement divided by your widest hip measurement—is also a good predictor of risk. 1.0 or above is greater risk, and desirable is 0.8 for women, 0.9 for men. See

But perhaps the best measure to use would be percent body fat (most accurately determined by underwater weighing, but indirectly measured with calipers or more high tech devices).
And yet I rarely recommend it. Why? Because we really don’t need another measure, another number to fixate on. If your weight is climbing out of range, you’ll know it. Take a look at your eating patterns, and activity. Focus on eating mindfully and separating physical hunger from all the other reasons you eat. Reread some past posts on this blog for more guidance!
And if your weight is above a “desirable” BMI, but has been stable for years, and you have normal blood pressure, cholesterol and blood sugar, let it go. As long as you can comfortably engage in activity to keep you strong and fit for years to come.

Friday, February 11, 2011

Diet Pill Death Shouldn’t Destroy Your Hope

Won't be long before they're pushing diet pills for him
Weighing In On the Risks of the "Quick Fix"

Another diet pill bit the dust. Last week, the FDA killed the promise of a quick fix for losing weight. They demanded of Orexigen Therapeutics a long-term study for safety, concerned about the possible risk of heart attacks that might result from use of Contrave, it’s new product. Apparently Contrave had already demonstrated success in raising blood pressure, something those with obesity hardly need to add to their woes.

So why a post on this? I am delighted with FDA’s stand, yet alarmed by the details of diet drug and laxative availability and the potential harm to users. Meridia, for instance, another useless diet pill, approved for 13 years, was only recently removed due to a 16 % increased risk of heart attack, stroke and death.

Chai, not Senna tea!
Some weeks ago I was visiting my mother, searching her cupboard for a tea I would like. “Dieter’s Tea” popped out, a product I was unfamiliar with. My mother, of course, didn’t purchase this product, but rather was given it “by a friend”. The box was open, but she had never tried it. No, she had no idea what was in it or how it “worked”. 

So I read the ingredients, and then began to Google. My greatest concern was the Senna. You know, that natural plant substance that helps constipation. Gotta be healthy, right? And here’s one of the many articles that confirmed my suspicion:
Because it is over the counter, readily available, comes without a warning, and marketed as a natural remedy, it is most worrisome. Because I know people are seeking a quick fix. And they are not researching the ingredients and their risks while at the supermarket deciding between Earl Grey and Dieter’s Tea.

 So back to Contrave.

At best, subjects lost 4.3 % more weight, compared to placebo, the fake stuff. If you’re 5’4” 175 lbs,, with a BMI 30, you’re considered obese, making you eligible to use a prescription diet drug.
In 12 months, that amounts to just over 1/2 pound additional weight lost per month, 2 ounces more weight lost per week. Wow! Rapid? Significant, even? Enough to justify the cost, either financially or medically? And risk free? Hardly.

Interesting, no?
How much health benefit would you gain from that additional 2 oz. per week?  And self esteem? Would it change how you see yourself? And would it justify the unknown risks? The potential changes in blood pressure and increased heart disease risk?
And how necessary is it anyway to lose weight if we are obese, but fit? Yes, those two phrases can exist side by side!

Some months ago, the promise of a new medication for MS hit the news. A pill, the very first, to offer hope for those of us living with this potentially debilitating disease. The advantages were clear. Swallow daily, or inject daily or multiple times weekly. And the studies showed the medication to be at least as effective as the injectables.

Aren’t you thrilled, friends and family asked, knowing my 8-year history with this illness? Yet all I could think about was the cost. Not financial, as I am fortunate enough to have good insurance coverage. But the risk of this new med, with its list of horrific potential side effects, including blindness and fatal herpes infection, to name a few.

Now if the benefit strongly outweighed the risk, it might be worth it. But, thankfully, I am not debilitated by my disease. I am lucky enough to be able to engage in all activities I care to. And it’s possible that you, at your current weight, may not be debilitated, even if your doctor sees your weight as the number one “disease” for you to tackle. See my point?

We all want a magic bullet, for everything. So we’re drawn to lottery tickets, diet pills, surgical fixes for whatever might hold promise of a better life.

Would a new diet pill really change anything, even, if compared to placebo, it took off 5 % more of your weight? Because that’s enough weight change necessary to get it approved.

Disturbing photo from the MFA, Boston
Finally, those of you at the low end of the scale may cling to the benefits of staying there. The fear of change keeps you focusing only on the positives of where you’re at. Is it really so positive? Is the benefit of your eating disorder really greater than the costs, physically, psychologically, socially?

Reminds me of how we remember old boyfriends (or girlfriends). We longingly recall all the great times, how wonderful it was being together. Until we reality check and remember—I was miserable with him!

In summary, be an accountant. Look at the list of benefits of staying where you are, in terms of weight and behaviors. Then give some serious thought to the negatives, the risks. And hopefully the risk of taking diet pills, laxatives, and cleanses in addition to your own unhealthy actions, will be reconsidered.

As always, I'm eager to hear your opinions!

Sunday, February 6, 2011

I didn’t throw away the leftovers.

Managing social eating situations

Cheesecake, with a side of fresh fruit for breakfast. 25 years of marriage and my husband has internalized my eating philosophy. It was a happy sight.

The homemade Grand Marnier cheesecake joined the butter cookies, rugelach, chocolate cake, biscotti, brownie, chocolate chip cookies, cheese, pizza, pasta in peanut sauce and other leftovers. 

No, I did not purge the rich pastries and appetizers, (enough to serve the 40 people at my home last night plus another 40)—not through exercise, and not into the trash. I did share some—there were lots to go around—but admittedly I held onto my favorites to enjoy for many a snack in the future. 

There were indulgences a plenty, accompanied by a wine tasting, a fundraising event (self-serving, I might add, for MS) I planned and cooked for between writing posts.  

And as I reflected on the evening of food and festivities I realized there was a lot to share about eating in social situations.

Maybe I’ll restrict before the event!

Oh, you should know better by now, if you’ve been reading my blog for awhile! But most people think that’s the best thing to do. They figure they should eat less in advance, knowing they will likely be tempted to eat more than usual. As a result, they arrive at the gathering or restaurant quite hungry, with little control over their eating. And so they overeat. Alternatively, they limit their choices to shoulds—you know, eating what looks appropriate or feels safe in the moment—then start overeating upon returning home. 
Or, the more anorexic among you may find you restrict in advance of the event, eat minimally, and then feel bad about something you’ve eaten, while not really excessive, and, eat minimally later on. As we both know, none of these strategies help you manage your eating and weight, regardless of your eating issue.

As for me? I started this weekend morning quite typically-with homemade French Toast (made from the leftover Challah shown on previous posts). I did my usual routine activity, had my usual meals and snacks. True, activity was slightly higher rushing around my kitchen, but that’s about it.
It’s hard to mindfully eat when you’re also the host. Hard, in fact to fully enjoy the event, even. But I chose what I really love (an amazing and easy to prepare walnut/pomegranate/roasted red pepper dip on bread, peanut noodles, and my husband’s homemade sushi.) 

I skipped the Root Vegetable Soup (I’ve been eating it for weeks). I loved my cheesecake, but skipped the other desserts (besides the fruit, which I hardly consider dessert).

There’s something about trusting that the food’s going to be there. No, I’m not going to make such a lavish spread any time soon. But I will, as always, give myself permission to eat the leftovers whenever I am hungry. Yes, even as I watched my husband doing, even at breakfast!

But won’t I double in size following your approach?

Apparently not. Here are some key points to help keep you on track:

   •  Choose what you really like eating. But eat only as much as you need.
   •  Allow yourself to eat more food later if you get hungry. Now is not your last chance!
   •  Eat normally before the social gathering! Don’t skip meals, fluid load or over exercise. Really!
   •  Ask for a goody bag! Bring some leftovers home for another meal or snack, allowing you to fully taste and enjoy them mindfully, and to prevent overeating.
   •  Eat your usual, adequate meals the next day. Even though you may be tempted, do not over exercise or under eat to compensate for the day before.
   •  Trust me. Take a leap of faith with this approach. And once you see how well it works, how much better you feel physically and mentally, you’ll start to trust yourself. 

And that’s the goal.

Tuesday, February 1, 2011

Lessons from the Tiger Mom

A Nutritionist's View on Achieving Success

Twice last week I was accused of acting like a Tiger Mom. Interestingly, the accusers were not my own flesh and blood. Rather, they were two patients, independently, who described my Tigress-like approach in my sessions with them.

Unaware of the Tiger Mom associations, evolved from Amy Chua’s book “Battle Hymn of the Tiger Mother”? Briefly, this Yale Law school professor recently published her memoir on parenting, Chinese parenting, focused on tough love strategies and exceptionally high standards. She writes that “an A- is a bad grade”, and has been known to reject her young daughter’s homemade birthday card, saying “I deserve better than this” throwing it back at her child. She states:

"Chinese parents can do things that would seem unimaginable — even legally actionable — to Westerners. Chinese mothers can say to their daughters, "Hey fatty — lose some weight." By contrast, Western parents have to tiptoe around the issue, talking in terms of "health" and never ever mentioning the f-word, and their kids still end up in therapy for eating disorders and negative self-image. ... "

While I admit to having not yet read the book, it certainly appears that success is measured by how things appear on the outside (such as mastering a musical instrument to perform at Carnegie Hall, as her daughter did at 14). Happiness, and psychological health, however, apparently are of no concern.

Now back to my patients. Neither Jane nor Dana was called names in our sessions. And my focus was hardly limited to external measures of progress, such as weight, for instance. Yet their descriptions of my counseling approach I could only translate as “Tiger”.  And rightfully so.

A literal “Ouch” was uttered, as I strongly linked Dana’s recent eating disordered slip with the very destructive pattern she sees in her mother. I very directly pointed out the inconsistencies between what she stated she wanted to achieve and her unhealthy behaviors. After much time working together, this grade was substandard and for eating disorder recovery, simply unacceptable. I told her I had come to expect better from her. And strict limits were set regarding behaviors that impacted her safety and the safety of those in her care. While her behavior is her choice, I could not support working together unless some clear limits were established, including accountability for medical stability.

As for Jane, who has been working with me for more than a year, she casually described (to an Intern sitting in on our session) my lack of warmth and fuzziness at our initial meeting. Perhaps she even mentioned distant? Can’t remember, or simply blocking it out. But over time, she reported, she saw another side of me. Let’s call it the Koala Mom side.

The Koala Mom, so beautifully and lovingly described by Dr. Amy ( is warm, fuzzy and supportive. She trusts her offspring have the competence and wisdom to do the right thing, to have good judgment, and to be true to them selves. Koala Mom offers a “safe place to escape from the pressures of the world”. And KM wants to build their inner strength so they can cope with disappointments and difficulties when they arise.

Perhaps it’s a bit of a leap, but the parenting role we play as counselors and nutrition therapists cannot be ignored. On the Tiger side, denying you privileges, including engaging in physical activity, traveling, even driving a car, is often essential—for your own safety. And often, few others will step in to set these very necessary limits. And if they did, if might be difficult to hear from those that are closer to you. These limits are set out of care and concern. They are not punishments, merely safety measures, road-blocks to prevent you from detouring into an abyss. I may present what appears rigid, (as described in a phone conversation with one parent today). Yet this very parent, in the same call described how safe and trusting her daughter had become of my guidance.

Yet if I fail to be appropriately nurturing, to be part Koala Mom, to support you in making your own decisions, I am truly sorry. It’s not that I don’t trust you. It’s not that I don’t believe your stated intentions. It’s just that eating disorders are fickle. They don’t always behave rationally and sensibly. Motivated to recover, you’ll come to appreciate this. Like Dana who admits that my direct and seemingly harsh stand, while troubling to hear, was just what she needed. Yes, it shook her up, and got her back on her feet. At least for now.

And so at times, my Tiger Mom side may emerge—seemingly strict, tough, heartless. Tough love, maybe, but with only the best intentions for recovery. But I hope you’ll have absorbed my encouragement and belief in your ability to get through. Perhaps, as patients have reported, believing in you even when you have stopped believing in yourself.

And hopefully you’ll know that you have a voice that I am always willing to hear—even if I don’t always agree what you might be saying.

You won’t always like what I have to say. (Or, the recommendations of your own nutritionist, or therapist, or doctor, if it goes against your unhealthy intentions.) But please consider that this seemingly callous approach is anything but. It comes from truly caring about your success and recovery. And the need to balance the Koala with the Tiger.

I'd love to hear what you're thinking, so please comment!