Monday, December 26, 2011

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

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

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

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

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

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

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

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

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

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

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

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

And I’m feeling quite good.

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

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

(See Cream Cheese Frosting Recipe below)

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

Cream Cheese Frosting

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

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

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

Monday, December 19, 2011

This Holiday Of Miracles—Ancient Wisdom About Managing Your Eating

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

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

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

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

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

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

Regardless of your particular culture or religion, we are all confronted by food challenges this season. And while I have addressed this subject in various posts previously,,, I thought I’d give a bit more support to get you through this challenging (yet potentially joyous) season.


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

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

Take control of portions

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

Choose what you enjoy. Enjoy what you choose.

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

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

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

Be prepared.

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

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

Consider your limits.

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

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

Happy Holidays!

Friday, December 16, 2011

The Gifts You Brought Me: Priceless Progress This Holiday Season

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

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

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

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

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

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

These have been the greatest gifts I could ask for.

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

Friday, December 9, 2011

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

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

Can you guess what he told her? 

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

Oops! I was planning on praising a doctor today!

The wisdom of Dr. Mars

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

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

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

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

My confession

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

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

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

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

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

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

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

And you?

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

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

Saturday, December 3, 2011

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

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

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

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

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

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

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

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

Laziness Keeping Her From Exercise?

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

Time To Change The Strategy

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

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

Information Can Cause Slips

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

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

What’s In It For You?

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

Advice For Fellow Healthcare Providers

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

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

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