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. 

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!

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.

The Quick Fix For Your Struggle With Eating? Patience.

20 years to construct Chateau de Chambord,
Loire Valley, France

I know you’re impatient. Everyone’s impatient—you are not alone. We want change to have already happened. And we want to be done with the struggle of eating—eating enough, not eating too much, eating just right. We want to be free of the rules and the thoughts, but are reluctant to invest the effort and time to enable it to happen. We make change, but it never seems good enough, and when it seems to be going along just fine, we fear we’ll slip up—and maybe we do. Quick fixes allure us, offering such promise. But this is not about quick fixes.

I’d like to wave my magic wand and make it all better. I do have a magic wand, but I’m saving it for when all hope is lost. And really we haven’t reached that place.

I’ve never built a house, but this analogy has crossed my mind many times. And you know once something is in my thoughts it’s challenging for me not to share!

Railroad house, Swiss Alps

Consider building your house

It starts with the foundation, which needs to be rock solid, firmly planted. Poured concrete, perhaps, definitely strong—at least after it has had some time to cure, to dry and set. And you’ve got to wait for that.

You could slap together some shoddy construction and it could look just fine on the outside—at least for some time. It may appear attractive at first, but with the first storm the siding may fall off, and the paint may begin to chip. The damage begins.

Restorations may take even longer. There’s some necessary destruction of the existing structure, which precedes the new construction, the rebuilding. And you have to pick and choose what you want to keep and what you’d like to discard in this new dwelling.

Such is the case of building a healthy relationship with food.

It takes time. After all, it took a long time to get into the mess you’re in now. And it takes a solid conviction that change needs to happen—because you believe in the need for change, not just your doctor, or your husband or your mother.

Return to trusting your hunger and your body’s ability to self regulate, if that was a part of your history, if you had once had a normal relationship with food. Remember how charming the old wallpaper looked and how comfortable it felt being in that space? Wasn’t it nice to be able to eat a couple of cookies or a piece of cake, without the negative self talk?

Or, was there never a normal relationship with food?  Was it always a relationship of shoulds and rules? Did you never feel safe listening to your internal cues? No feng shui when looking at the wall colors of the past rooms? Sure, it’s more challenging restoring, having never followed your internal compass—getting rid of the old thoughts and habits, and redirecting toward healthier behaviors.

Discarding old beliefs and unhealthy views requires some trust that your house will still be able to stand, without the supports of unhealthy rituals and black and white thoughts. The new pieces of information get tried on, sampled, then permanently attached, as you see their value and beauty.

You need to be able to weather challenges. Stressors, like strong winds and snow, can knock you down. But the more solidly you have set your foundation, the less damage will occur. For instance, keep structure to your day’s eating versus skipping meals. You’ll feel less vulnerable and therefore better able to handle the stressors. And remain fixed in the belief that yes, you are worth it, you do deserve to feel well, to take care of yourself, to eat. These are your cement.

It may take some time for these foundational principles to set, but adding supports can help.

Actually, he's a Swiss Alps goat farmer, but whatever!

Who are your craftsmen? Those who you select to labor on this building with you, whom you rely on to direct your project and provide a vision?

Select a team of with experience—your MD, therapist, RD. And surround yourself with laborers that have the same vision and can support your project, not pro-Ana sites, or diet programs failing to address your behaviors and thoughts.  Contract with friends and bloggers who can assist you in getting the building done, and can support your repairs as soon as they need to happen.

Building this chateau (Chenonceau) over water 
must have required great vision.

Quick fixes, like sloppy construction are destructive. I’ll just restrict now (and deny my hunger), just for this week, she told me, or just until the holidays, he stated. It’s like leaving off the insulation and expecting you’ll still stay warm. Okay, perhaps not so bad at first. But then the pipes freeze, and then burst, and now you’re left with major water damage and repairs to be done. After restricting, you may eat more than you intended, and then purge, or continue to restrict. Now your signals get confused, and distinguishing hunger and fullness is a challenge. Trust is lost, and your ability to self regulate. Never mind the damage to your body, your emotional state, and your belief in yourself. The thermostat stops working.

But it can be repaired

This medieval castle in Carcassonne, France was partially
reconstructed. Turned out well, no?

Repairs? Yes! Because slips happen (a new bumper sticker, perhaps?) Over time, damage may occur—a tree may come crashing into your house, a window may need replacing. Slips are a normal part of maintenance. But wait too long to work on quality repairs and soon the wiring will also be affected, or the cost of getting the work done will be too great. I can’t miss work to do an eating disorder program, can I? Or I don’t have time to see my nutritionist and my therapist regularly!

Don't hike up Peyrepretuse, in France, unless
your house is solid.

Remember, it gets way more costly putting off construction and renovation of your house. Consider starting now, from the ground up. Gather your team, and start pouring your foundation. And take the first steps to drafting your blueprints for a better relationship with food.