Sunday, July 29, 2012

Forgetting to Remember: The Key Obstacle to Eating Disorder Recovery

In Memory of a Lost Patient.

Maybe it’s because I was taught never to forget. I was instructed to mark days for the sole purpose of remembering—the anniversary of a loved one’s passing, a date of destruction of a holy site, or the attempted annihilation of my people throughout history. Recalling a negative occurrence, as I’ve learned, has much value. 

I’m not suggesting dwelling on it, as a kind of “woe is me” way of existing, thinking catastrophe may strike at any time! But remembering negative events reminds us of our good fortune to be where we’re at, to appreciate all we have, all we have survived. And it reminds us we need to be anything but passive to ensure that we do our part to prevent future damage and disaster.

And what does this have to do with you, my dear readers? Everything! If you read Drop It And Eat for support with your eating and your health, for the sake of changing your relationship with food, then forgetting to remember is a key obstacle to your progress. Are you a dieter or a restrictive eater? A binge eater or someone stuck in a purge mode? Your memory is essential to breaking out of the trap you’re in.

Here’s why.

When you are restricting you may focus on the high you get, how empowered you feel—yet forget that it is but a fleeting feeling. Rather, the restricting has landed you with rebound overeating or disappointment with subsequent weight regain.

Alternatively, you achieve your “success”, and the restriction continues, only to result in symptoms, health risks and hospitalizations.  You forget the lightheadedness, the risk when driving alone or with those in your charge. You fail to acknowledge that fuzzy headedness and the fact that slowed thinking is not your norm.

Maybe if you remembered that weight loss didn’t itself bring you happiness, that goal weights were a moving target. That no weight was ever low enough, and that it never made you feel good enough.
You’ve forgotten that the isolation from friends and detachment from those you love was a hefty price.

You’ve forgotten how scary it is to vomit blood, to see the veins pop in your eyes—but instead you simply focus on the risk of keeping those extra calories in.

You get so used to living in a substandard way, not functioning at full capacity, that you forget what life could be like—the potential you truly have to make a difference, to even one person you care about.

Before the memory is gone, recall it. When you are considering rigid dieting or the need to purge, think about what you know. When you are thinking you already blew it, that it hardly matters what you do at this point, consider where that has gotten you. Was the action worth it? Did it really achieve your intended goal? Is this how you want your life to be?

Do not forget that your thoughts used to be spent on passions and hobbies, on family and on learning—not singularly on calories and carbs, and pounds and numbers, on shoulds and shouldn’ts.

Remember that you are worth it, that you have made a difference and that it is not too late to change your eating behaviors.

This post is written in memory of my one patient who left this world too soon, well on her way to recovery from her bulimia, but struggling with her bipolar disorder. Her memory inspires me to do my part in eating disorder recovery.

Friday, July 20, 2012

Who’s Telling You What to Eat?

RDs? Nutritionists? Trainers? Finding healthy, sensible advice to change your relationship with food.

Don't let me teach you to juggle! And don't let some
clown pretend to be a nutrition expert!
I thought about doing a spinal adjustment on my overweight patient with back pain, but then I realized “Hey, I’m a dietitian, what am I thinking? I have no expertise in this!”

Ok, I’m kidding. I wouldn’t dream of guiding clients in areas I am not qualified (although I have made suggestions about stress reduction I would never consider myself a replacement for a therapist). Educating clients on target heart rate and setting realistic exercise goals based on their current health is one thing, but I wouldn’t instruct them on bench presses. Subtle mistakes and misinformation could lead to major problems.

So why don’t other provider types feel the same way when it comes to doling out nutrition information? Take chiropractors for instance. What extensive training qualifies them to tell you how to eat? Or to sell “toxin cleansing systems”, aka serious laxatives, to bulimic patients (I kid you not), all for the sake of a giant profit? Yes, I really had to coach a patient to return a product to her chiropractor who had convinced her that this was the answer to her woes. Thankfully, I was successful.

Trainers and coaches, perhaps well educated in their field getting people exercising, seem to misinform their clients more than most practitioners, requiring a great deal of my time to correct. They propagate fitness magazines’ and supplement manufacturers’ myths about carbs, and protein (they see a major halo around this nutrient) and base their guidance on their own unhealthy beliefs. Not all providers, of course—but many. They share what they believe has worked for them—which has little to do with what is healthy or appropriate for you! Even the Pilates studio I go to is now selling purgatives in pretty packaging suggestive of clean, fresh and natural health. If only they were aware of the damage of these senna filled disguises. Uggh!

I can at least support the "celebrate recovery"!
Then there are those that proudly call themselves nutritionists, which is actually quite a meaningless term. A nutritionist could be a steroid-infused guy pushing supplements at the local vitamin store, with no qualifications for this position other that his availability from 9-5. Or it could be the produce manager at the local Whole Foods or other market. Yes, anyone can call himself a nutritionist.
Admittedly, I too, have referred to myself as a nutritionist—a nutrition consultant my business card still reads. Like others, I began to use this term as a way of differentiating myself from the stereotype of food service dietitians of days gone by. It was a way, perhaps of putting a more updated spin on who we are. The difference, though, between me and those other nutritionists is that I also have very valid credentials in my field—RD, MPH, CDE, LDN (see below for definition of these credentials).

Why should you care about the initials?

Credentials are not just for bragging rights. Rather, they help to separate providers based on their qualifications. There are many bright and well-educated nutritionists—faculty members, PhDs often, who are not Registered Dietitians but rather academics with post docs in nutrition. But while they may have a wealth of wisdom about nutrition research and science, they often lack the clinical and likely the behavioral expertise of someone with an RD with years of experience working with patients. As a result, their recommendations may be less than realistic.

That said, credentials are just a starting point. There are many RDs with good qualifications that I would never refer to—they are too inexperienced or rigid in their approach.  So if you are looking to work with someone, it’s critical that you learn about their experience, their philosophy and their approach to shifting your relationship with food.

Potential for danger

A sign I came upon in Zermatt, Switzerland
A family member living in another state recently contacted me about the guidance he received from a nutritionist. He was instructed on a Paleo Diet—apparently what this nutritionist puts everyone on, regardless of their symptoms. When his symptoms worsened, she said to switch to gluten free and lactose free. But she also suspects heavy metal toxicity. Or, she added, maybe a parasite. Or something. But in the meanwhile, she prescribed her diet  “remedy”, with absolutely no evidence to support it. Oh, and she strongly encouraged a paycheck's worth of supplements which she could conveniently sell him.

And in the meanwhile, this relative is wasting away from his already underweight place. He’s feeling weaker and is nutrient deficient. But he clings to the very personal guidance he’s getting from the nutritionist. MDs have not yet identified his diagnosis nor cure, but this nutritionist is giving him hope. The problem is, this hope comes with a price; namely reducing his energy level and his muscle mass, imposing restrictive (and unnecessary diet rules) and dangling more hope that there is more this quack can do for him.
Perhaps it seems harmless enough. After all, he wasn't getting anywhere with his regular practitioner.

But it absolutely is harmful! Restrictive diets that result in weight loss in those in no position to be losing weight are irresponsible. They may stall constructive, valuable follow up with appropriate specialists. They add confusion to an already overwhelming treatment course. And they provide a false sense of trust—and hope.

Finding the right dietitian

Sometimes, it's hard to know what advice to take!

  • Philosophies may vary, but I’d suggest avoiding anyone suggesting you eliminate whole categories of foods or nutrients, such as carbs, grains, dairy, etc.
  • Avoid those whose recommendations are based solely on their personal experience and lack evidence-based recommendations. It’s no better than a LICSW who starts her session using Tarot cards (this, too, I’ve heard about). Fun, maybe, but not a sanctioned, proven therapy!
  • Learn about their experience treating those struggling with your particular issues. More experience is best, of course.
  • Do they come recommended from other health care providers or peers you can trust? Do they work in collaboration with your other practitioners? This, too, is critical.
  • Do they believe you can change? If they view you as unfixable, damaged goods, discard them and move on to another provider, please!

We are bombarded with nutrition information and much of it is conflicting and inconclusive, some of it downright wrong. And the more confused we get, the less likely we are to take action, to make the necessary changes to support our health.

So choose your providers cautiously. Select those that can intelligently sort through the overwhelming overload of food rules you’re hearing. And be on guard for quacks and those simply stepping out of bounds, dispensing information out of their field. Or even worse, selling you useless and often harmful products for their personal gain.

As for my philosophy?

How great is this?!
You can purchase it from their website:

  • Maybe it’s because I’ve got 26 years of experience behind me. Or perhaps it’s the effect of being diagnosed with a chronic progressive disease (I’ve got Multiple Sclerosis). But personally and professionally I’ve come to believe that life is too short to deny ourselves what we truly enjoy eating. Of course, if you’ve got a severe food allergy (or other such condition) and your survival depends on dietary changes, that’s obviously quite different!
  • You need to weigh the costs and benefits of dietary and lifestyle changes. Sure, weight loss may be appealing, but at what price? Is it really worth the deprivation, the denial, the decreased energy, and the obsessive thoughts to achieve an unrealistic rate of weight change or even an unhealthy weight?
  • Food should be enjoyed with all your senses—regardless of your weight. Everyone deserves to nourish himself and to enjoy eating.
  • Change is challenging, but worth making to improve the quality of your life. And it’s not too late to make it now with the help of a qualified RD.

The credentials:
RD: Registered Dietitian
MPH: Masters in Public Health, in Nutrition (UNC Chapel Hill)
CDE: Certified Diabetes Educator
LDN: Licensed in the state of MA
Not listed: BA in Biology, Brown University, Providence RI.

Saturday, July 7, 2012

Carbs Still Don't Make You Fat. But Taubes' Words May Make You Crazy

Don’t do it! Don’t dump your carb-rich foods because of yet another Gary Taubes’ article, which hand picks research to make for sensational headlines that successfully get propagated in the NY Times (albeit just in the Opinion section, not the Science one, thank God!) Yes, yet another news piece inappropriately attacks carbohydrate, failing to note the study’s limitations and the risks of jumping to irrational conclusions.  I’m no researcher but I’m a critical reader of research. And I find Taubes’ (and other such articles drawing false conclusions) simply appalling.
Serve with a Greek yogurt and include the nuts and the
glycemic load is lowered. Better than given this favorite up!

Taubes pulls from a recent study by Ludwig and colleagues at two well-respected Boston hospitals. The objective was to examine the effects of 3 diets with different composition of protein, fat, and carbohydrate and glycemic load, on metabolism. This was done on overweight and obese 18-40 year olds following a weight loss of 10-15%. Glycemic load refers to how much a food will raise blood sugar compared with a standard. It takes into account the amount of carbohydrate in a food, as well as the impact of that food on blood sugar.

Here are a few facts to consider. Taubes' carb-bashing article ignores some critical points, many highlighted by the study authors themselves:

• Total sample size of this ground-breaking study? 21—an embarrassingly small size to be drawing such global conclusions! Perhaps even more striking is that the study began with 32 participants--that's a 34% drop out, in spite of a $2500 financial reward for full participation. I am left wondering why such a high drop out rate? These were self-selected participants, in response to an ad. Were the results not as satisfactory in those that dropped out? We'll never know, but I could only guess that if they were satisfied with the weight loss and maintenance results they might have been inclined to stick with the study. If we had all 32 starting participants perhaps the results would be quite different.

Carb-rich wheatberry salad--a summer favorite!
One of 25 recipes at
• The study looked at the impact of three different diets after weight loss, which might be quite different than the impact on those whose weight has been stable. The body does act differently after being starved!

• 1 month per diet type only! That’s how long the study evaluated these various diets.

• Even if this were all valid, would the subjects actually gain weight? It is unclear, given these were not free-living conditions and resulting weight changes were apparently not explored. In fact, we have no evidence of how closely these diets were actually followed, given this was an outpatient setting. The study mentions likely predictors of future weight change (such as changes in metabolic rate), but no actual weight change data on each of the diets is described. Yet Taubes certain jumps to this conclusion.

• Even if they did gain more on a higher carbohydrate diet, there were 2 very negative effects of the lowest carb diet, that may result in long term serious consequences.  Both urinary cortisol levels (a hormonal measure of stress) and C-reactive protein (a marker for chronic inflammation) increased. And both of these are associated with increase risk of cardiovascular disease.

• With the most minimal effort on Pub Med, I found another study on the pediatric population exploring high and low glycemic load meals on energy intake, satiety and hunger. Guess what this study concluded? That there is no evidence for this population (of Hispanic youth) that changing the glycemic load effects short term hunger, fullness, satiety or energy intake. BTW, this one was also by Ludwig and colleagues. In fact, even in the study Taubes reports on, there is no advantage in terms of subjects sense of hunger on the three different diets.

• The authors of the study (not Taubes) state: 
Low carb? absolutely! But not without its risks.
"These findings suggest that a strategy to reduce glycemic load rather than dietary fat may be advantageous for weight-loss maintenance and cardiovascular disease prevention."  
Yes, reducing your intake of fat to very low levels is quite senseless. But no one is advocating for a diet rich in saturated fats, like those found in the meat above. Yes, fats are a welcome addition to diets, even for those watching their weight! And key words to note here are "glycemic load". In other words, think balance. Meals with a combination of protein, fat and carbohydrate will have only a moderate glycemic load, and that is what may be key--both for metabolic health, psychological well-being (think avoiding deprivation) and long term adherence. Yes, the study authors have the wisdom to add:
"Ultimately, successful weight-loss maintenance will require behavioral and environmental interventions to facilitate long-term dietary adherence." And they acknowledge that the study diets were not designed for long-term practicality, and that the very low carb plan would be difficult to follow long term.

Having worked with many thousands of individuals to manage their weight, I stand 100% behind including carbohydrate to do so. Carbohydrate-rich foods are a necessary, satisfying, and energizing part of a healthy diet. I urge caution to the public, which may be less experienced at reading such strong-stated opinions as Taubes' as if they were fact.