Monday, February 27, 2012

Advice for Your Doctor for NEDAW

Call me crazy, but I’m tempted to respond to a doctor’s closed-ended questions in ways that would knock his socks off. When he asks me about alcohol, for instance, he frames it something like this “you don’t drink much, right?” Or perhaps to assess risk of STDs he suggests “just one partner—you’re married, right?” Well, yes, he’s right, but would I ever say anything other than what he’s led me to believe is the only acceptable answer possible?

Isn't it time to get the support you need?
This brings me to the important topic of educating your healthcare team, your doctor, in particular, about how to truly support you. In honor of National Eating Disorder Awareness Week (NEDAW) (here in the States) I thought that health care providers could use a bit of awareness, to hopefully make your visits, and your life, a bit less stressful. Please consider adding your own two cents to the comments—then pass it on to others—and your providers! While this is prompted by NEDAW, I’ve included recommendations that are worth sharing regardless of whether you struggle with an eating disorder, disordered eating, or simply are outside of what the BMI chart says you should be.

Unsolicited Advice From One Healthcare Provider To Another

On weighing your patient

Please weigh patients with their back to the scale. Have them remove all layers possible—most individuals, regardless of their weight, want the weight to reflect what’s real. Weighing with shoes, heavy belts, and jackets doesn’t contribute much valid information. Oh, and have them empty their pockets!

That said, some do want to misrepresent their weight—so less is always better—with regards to clothing. And have them empty their bladder first!

A poker face and restraint from commenting is wise. That is until you’ve gotten to assess their weight in context. Imagine if you said to an overweight patient—“great, you’ve dropped a ton of weight” only to realize that they had a rapidly growing cancer? 

Weight change must be evaluated relative to behavior. Someone who lost weight (regardless of how appropriate you thought it was for them to drop some pounds) may very well have gone about it the wrong way. 

Consider this—they may have been starving themselves, resulting in messing up their periods, their metabolic rate, their mood, their sleep, their thoughts, their relationships.  This is nothing to offer positive reinforcement for. There is nothing healthy about losing weight this way. Perhaps they are compulsively exercising, or dehydrated from purging or laxative abuse. No, weight would not be a good measure of health then.

Similarly, your patient with a high BMI might have simply maintained her weight. But she feels well, is active and fit, and is healthy by all measures. Maybe she has even turned things around, if her weight had previously been climbing. Sure, you can explore other risk factors, such as quality of her diet—as I hope you would do with your slim patients, too. But if all looks good, perhaps you can accept that her stable weight is just fine for her.

Perhaps if she’s been climbing in weight that might warrant some probing about recent lifestyle changes—stressors, activity, diet—to help with better self care and disease prevention.

And if your underweight anorexic patient has increased his weight, please similarly temper your response! While you may be delighted, he (or she) may not be. It’s a mixed bag, gaining weight, even for those who are trying to gain weight. There’s the healthy side of them that really wants to recover. And then there’s the eating disorder voice that sees weight gain as a failure, as a “you can’t do anything right”, pulling them back to restricting again. It’s more valuable to elicit a sense of what they are thinking and feeling about the change. How does it fit with what they expected? What are the benefits of the changes they’re making? Focusing on the behaviors that contributed to the weight shift is more valuable than discussing the weight itself.

If your patient isn’t doing well, rest assured that they are as frustrated—even more so, really—than you are. The impact is far greater on them than on you, that’s for certain.

Hooray! You got your period back!

It’s not healthy to lose one’s period due to such factors as anorexia, restrictive eating, or compulsive exercising. We all know that. But while getting a period back is a good sign, it is not always well-received by patients. For some, getting a period equals “I must be fat now”. For others, it means they are done with their efforts to change their eating and behaviors. And that may be the worse thing for them to conclude.

Periods may return before weight is restored and before behaviors are normalized. Or they may come back after 4-6 months after stabilizing in a healthy range. Or they may never have disappeared, as was the case of a patient of mine who conceived 5 children through her years living with anorexia. The point? Consider where your patient is at before you rejoice in their body’s normalizing their periods!

Don’t Ask, Don’t Tell? I Don’t Think So.

If you don’t ask the right questions, you won’t get the real answers. So do ask open- ended questions—different than what my MD thought to ask—to obtain valuable information. If you’re discussing weight or body dissatisfaction, do ask if they’ve used laxatives, or diet pills, or vomiting or restricting—in the past, or currently. Suggest a frequency, in a non-judgmental way. If a patient says she purges daily, follow with a question like “how many times per day?” And when he says twice, follow with “And what’s the maximum?”  Just like if they say they have a couple of drinks, follow with what’s a couple—4? 5? 2? Per day? Per week? Suggest a range of possibilities, without raising an eyebrow.
We can only help our patients if we can accurately assess their situation. And, we can’t begin to do so if they feel they can’t trust us. So do your part. Ask your questions in open-ended ways, and be careful how you react. Ask how you can help, what they need from you. Are they connected with appropriate resources, or do they need guidance?

Encourage a follow-up sometime soon! 

Suggesting a 3 or 6-month follow-up visit certainly sends the message that their situation simply isn’t worth your taking too seriously. And as a result, they will undoubtedly convince themselves that really everything is fine, that nothing really needs to change.
And if you don’t believe me, read the comments from those in the know, below.

Thanks for taking the time to read this.

Monday, February 20, 2012

My High Calorie Intake Could Make Me Forgetful?

A Response to the Mayo Clinic's Press Release on Overeating and MCI

UPDATE! Read the response in "comments" from the primary investigator!

Yes I'm distressed!
I'm pretty worked up right now. Could be because the media is suggesting I should eat less, and I don't like it when I'm told to eat less—particularly for no good reason. And maybe it's because I take my mental function seriously, particularly living with Multiple Sclerosis, which can impact cognitive function. So best not to make unsubstantiated claims about what's gonna impact things like my memory unless it comes from good, solid science.

I'm perplexed. Could I really be the only one who sees the great irony in the opening statement of this Mayo Clinic press release stating that higher calorie intake, as self-reported by those with memory loss, ages 70-89, is associated with greater mild cognitive impairment (MCI)? Under the title Overeating May Double The Risk Of Memory Loss  the authors conclude "Cutting calories…may …prevent memory loss as we age." The study suggests that eating "too much" (more than 2,143 calories) may double the risk of memory loss.

Yes, the very people assessed to have the worse cognitive function reported the highest, sometimes extremely and unbelievably high calorie intakes. And as the press release video reveals, we're talking significant impairment (as in “Oh my, I've forgotten I was supposed to fly to New York yesterday" — oops!)

"Vell, I believe I had a couple of chickens, a pinch of shmaltz,
a few spoons of potatoes and a pint of borsht."
It's well established that self reporting dietary intake is full of errors—generally, the underweight err on the side of over-representing food intake, while the overweight do just the opposite. But self-reporting by the cognitively impaired? Is this some sort of joke, an April Fool's prank come early?

Even self-reported food intake using a validated assessment tool has its faults. (As in the Harvard study.) Being validated does not mean that the findings are real, that they reflect what was truly eaten. It merely addresses reproducibility. In this Mayo Clinic study, the only thing that was truly confirmed (as reported in the press release) is the degree of impairment, as assessed by more than one source. So we know participants are truly cognitively impaired, but we don't know with certainty how much they really ate calorically in the preceding year they were reporting on. Quite the population for accurately reporting, retrospectively, the amount they ate!

Maybe, given their MCI, they've forgotten how many portions they really consumed? Or perhaps they forgot that we typically don't report these things honestly.

The Joke is on Us

So here's my beef. The Mayo Clinic's press release, and subsequently the media outlets which picked it up, misled us. Even if my reasoning is off and all of the potential places where the science seems shabby were fully explained in the full study (which is yet to be released) there remains this problem—the media's conclusions suggest causation when at best we have an unexplained association.

The research summary states that higher calorie intake is associated with more cognitive loss (but does not necessarily cause it). So to then conclude, as most every article has, that we should be reducing our food intake, “cut out the chips” even, limiting our calories to prevent memory loss couldn't be more absurd! How unreasonable to manipulate us with these faulty one-liners, these irresponsible conclusions.

The Real Answer May Lie With BMI

The study controls for variables that might otherwise have confounded or confused the results. The researchers appropriately ensured that the finding, the increase in MCI with higher calorie intake, was not the result of such variables as diabetes, stroke, and, important to this argument, BMI. In other words, if I understand the press release and study abstract correctly, the increase in MCI associated with increased calorie intake at the highest intake levels, was not due to BMI. So BMI would not have been similarly increasing along with the cognitive impairment. Or, for that matter, with caloric intake.

So here's where I run into some difficulty. The study is stating that some, many individuals ages 70-89 years, are consuming > 2,000 to 6,000 calories daily, if we believe what they self-reported. And this is not linked with increasing BMI? If it isn't, that means people eating a rather extraordinary amount of food have no higher BMI than those at lower intakes. Soooo, if they are eating so much, but don't have higher BMIs, than how do we explain this?

There are several possible explanations. They could be expending more calories from exercise. Yet from the abstract, there was no mention of activity level—a major omission if we are assessing intake and making claims regarding the effects of intake without exploring output. Maybe it's exercise that's linked with MCI, for goodness sake, as exercisers would need to be eating at higher calorie levels. “Exercise Causes Cognitive Impairment.”  Wouldn't that make for a headline!

Or, maybe there is some other medical explanation for such high intakes without resultant higher BMI. Are they malabsorbing—as in such conditions as celiac disease? This would result in nutrient deficiencies, which certainly may be responsible for cognitive losses.

Or maybe they have some thyroid condition, or cancer, not yet diagnosed, which may account for greater expenditure of calories, and may also impact cognitive function. I am no expert on memory loss—that I can say with certainty. But it appears the researchers have not done due diligence regarding their study and its conclusions.

In fairness, all the answers may be in the full research paper, yet to be published. Yes, I requested it, but was only presented with the abstract and the press release; even my questions regarding exercise were ignored.

Even referring to the higher calorie intake as “excessive” or "overeating", leaves me scratching my head—on what grounds? If you are more active than your peers at 75 years old—still playing tennis, walking regularly, golfing in your retirement years, even hiking as I've seen many a 70 and 80 year old do—wouldn't you need to be consuming more calories? Why should they be labeling this higher intake excessive, unless it is resulting in an undesirable weight increase outside of their normal range? But I didn't see this addressed in either the abstract or the press release.

And why should you care?

You, my readers, do not match the profile of the study participants in terms of age. But you are being irresponsibly told that lower calorie intake may prevent cognitive failure. And when it comes from a reputable establishment such as the Mayo Clinic, and sealed as a reality in the written word of such media outlets as the Wall Street Journal, Time Online, and others, you'll believe it.

You'll believe that higher calorie intake is detrimental—regardless of your caloric need. And then another study may arise (like the Harvard study) drawing similarly inappropriate conclusions, and you'll buy into those senseless conclusions, too. And soon you'll be so inundated with all this "science" that you'll be overwhelmed about what you can eat and what you should avoid and how much. See the problem?

What can you do? Don't be too quick to accept the written word as fact. Await a follow up study that might confirm findings. And be careful about where you get your information. Sure, reputable resources are better than sites promoting and selling something, with a financial interest in convincing you of the value of their words. But even seemingly solid institutions and individuals can draw the wrong conclusions. When in doubt, discuss such articles with those capable of shedding some light on the findings.

The unfortunate end result of early publication of scientific studies is a loss of trust. Studies that haven't yet made it for publication in peer-reviewed journals have no place in the hands of the public. Misinformation runs rampant, and as consumers of this information, we are left overwhelmed and confused. And it's a bad state of things when we can't trust science.

Friday, February 10, 2012

Your Turn To Give Advice To Me

I’m working on a project relating to practical steps for recovery, and I need your input. If you are recovering from an eating disorder, please take a moment to send me your thoughts about the following:

  • What are the safest foods for you to eat? 
    • Please respond with a particular food item(s), category of foods, or nutrients. And feel free to address the type of preparation, if it contributes to the ease of eating
  • What are the characteristics of a food that makes it easy to get in? 
    • Ready made? 
    • All-in-one-dish recipes? 
    • Low Fat? High Fiber? Whole grain? 
    • The flavor or lack thereof?
    • Portion size?
    • Calorie-dense or low calorie density? 
    • Trusting because someone else has been able to eat it?
    • Trusting because you believe it to be good for you?

  • Which of the following, if any do you own? Do you use?
    • Crock pot/slow cooker?
    • Rice cooker?
    • Panini/sandwich maker?
    • Microwave
    • Telephone (to have someone else bring you food?)

Thanks so much for contributing! Please share this with your friends so they may help too! I’ll be sharing more about the project sometime soon!

Wednesday, February 8, 2012

Mindlessly Eating And What You Can Do About It

Shifting Toward Mindfulness

Can I argue with today’s NY Times article on mindful eating and its benefits? Me, this blog writer, who’s promoted a non-diet approach to eating with a mindfulness focus for the past 25 years of practice? Of course I fully endorse the contents of their piece! Yet I’m left wondering—why is this news? Overweight and underweight alike have been guided and supported by me to mindfully eat through:

  • Separating eating from distractions
  • Sitting while eating
  • Plating food, putting packages away
  • Setting a pleasant table to encourage sitting at it
  • Removing visual cues to eat (so that eating is an intentional act), including keeping food in the cupboards, not on the counters, and avoiding family-style serving
  • Acting as if our car is brand new—or has just been cleaned; keep food out of it
  • Delaying second helpings by more than the useless 20 minute rule, as it takes way longer for true satiety or fullness to hit, to discourage overeating
  • Focusing on eating with all your senses—smelling what you are about to eat, seeing it, hearing it’s crunch or its sizzle, noting its texture, and enjoying its various flavors
The real news is not that mindfulness is valuable. The real work to be done is to understand why we eat mindlessly. Because many of us consciously, mindfully even, choose to eat mindlessly.

    You know that eating in front of the TV will allow you to not be accountable—you won’t have to acknowledge how much or what you’ve just eaten. (For many of my anorectic patients this distracted eating is invaluable, quite beneficial at first, as it enables you to begin to eat without focusing so much on the food. It’s just what you may need to do).

    If you don’t fully use your senses as described above, then there’s less fear you’ll enjoy the food so much you’ll be unable to stop eating.
  • Because you don’t feel entitled to eat—perhaps because you think your body size doesn’t deserve to be fed, or satisfied, perhaps because you believe you should lose weight or because you overdid it earlier in the day or the week.
  • Because we believe that nothing will meet our need better that numbing out with a pint of Ben and Jerry’s premium ice cream, that nothing will soothe us more than the rich and creamy, forbidden foods.  
  • Because it meets some need that we haven’t been better able to cope with, because we feel hopeless, or undeserving of feeling better, because, because, because….

In these situations, not being present while eating may work like a dream. Detaching and eating may seem like just the answer.
But ultimately, this will fail you. Mindful eating requires more than mindfulness of the setting and of the food.

Self-regulation for weight management requires awareness—of hunger and of fullness. Eating enough is not based solely on the calories—but on satisfaction, on the experience and pleasure of eating. If you’re underweight and struggling to gain, maybe mindless eating is a helpful short-term strategy. Ultimately, though, you will feel more in control if you are aware of your intake. And, if you begin to allow yourself to truly enjoy eating.

Ask yourself –Is it hunger—true stomach hunger, or just an appetite to eat? Is it your reward for a hard day? An “I deserve it” of sorts? Is it punishment for “blowing it” or other self-sabotage? Is it “I’ll eat this because nobody can see me, because I can”, so called opportunistic eating? It requires awareness of eating triggers that we’d generally rather not address. It seems so Zen, so easy in this NY Times article, but it takes a major shift to eat mindfully.

To approach mindful eating, you need to ask yourself a few questions. Not just “Am I hungry?” an essential first step, but “What am I looking for this food to do?” And when you do eat without regard to hunger or fullness you need to ask yourself, “Did this work for me—beyond the moment? Or am I left feeling as bad, or worse than I did before I started eating?”  

Then next time you’re about to eat, think first about the consequence of eating mindlessly. Will it really be worth it, worth the distress afterwards, to mindlessly overeat?

Mindful eating is achievable and worth striving for. But a necessary prerequisite is being adequately fed—avoiding long periods without eating, and being prepared with adequate meals and snacks. You’ll be in much better shape for tackling those vulnerable times when mindless eating occurs.

Friday, February 3, 2012

You’re Only Cheating Yourself

Her binging and purging has abated at last, only now she’s restricting. He’s finally increased his food intake, meeting the goals we had set. Only now he’s taken up running—with a passion. She’s adhering to her meal plan, eating all that her body desperately needs. But at present her self-injurious behaviors have flared up.

Carnival photos courtesy of Cate (see link below)
As I sit with my patients I feel a bit like Temple Grandin, the autistic woman depicted in the movie by the same name, who visualized most everything she heard. Whack A Mole comes to mind quite frequently as I hear their stories. No, nothing too sophisticated or deep—just Whack a Mole. You know, that carnival game where you have a mallet and the goal is to hit as many of those furry rodents as possible that pop up out of their holes. It goes like this—you hit one, and just when you’re feeling pretty good about it, rather accomplished in fact, another rears its head, causing you to pounce on that one, too. And so it goes. If you do really well, you get a small, cheap stuffed animal—one that costs about a fraction of the money you just spent entertaining yourself. Here’s where this analogy ends.

Real life Whack a Mole, aka eating disorder recovery, is anything but entertaining. But the reward is invaluable. And while it, too, may have its costs—time for appointments, increased anxiety, a sense of loss of identity and of control—the rewards are immeasurable. Surely you could come up with a list of the benefits?

The carnival game analogy crosses my mind with many non-eating disordered patients struggling with weight management, as well. This I visualize more like the shell game—the old gambling game also played on city streets. Three shells are placed on a table, with a pea beneath one of them. With rapid moves of the hands, the shell guy shifts around and around, and the player struggles to identify where the pea is hidden until all hope is lost—by the player, that is.

The connection, you’re wondering? Patients often start off frustrated that their efforts to shift their behaviors, to make a difference, are in vain. They trick themselves into believing that after completing their workout, a reward of a Starbucks frozen beverage topped with caramel and whipped cream is in order. Or while dining out, they choose an entrée they feel good about, only to eat a portion that significantly exceeds their need. Or they choose what they deem a healthy snack, consuming it mindlessly in front of the TV, failing to acknowledge or to experience the pleasure of what they’ve consumed, ultimately leading to more overeating. And as a result they feel hopeless, that they can’t win at this challenge.

Naturally, this is reasonable at times. But what is senseless is the assumption they have been deceived, like in the shell game. Their expectation is that weight loss should be occurring, given all the work they’re doing, all the changes they’ve made. Yet in reality, sometimes they are simply just moving the shells around, so to speak.

Yes, it takes more than this for change.
Finally, we are sometimes likes hamsters in the wheel of life. We go round and around, doing nothing differently at all. And doing the same thing over and over when our experience tells us it just isn’t working for us, doesn’t move us forward. Uggh, more frustration.

It’s my hope that these visuals will provide you with more than just entertainment. Rather, may they inspire you to be more constructive—to act on your motivation, to challenge your thinking, to break from your behaviors—like Temple Grandin, who exceeded, I suspect, even her own expectations, living with a condition for which there is no easy fix.