Saturday, December 28, 2013

“Just Eat it”? Taking that leap of faith to let go of the diets and the rules.

Just Eat it. Designed by Olle Hemmendorff for Nike.
Just Do It has been a memorable Nike campaign, motivating and inspiring athletes and active wannabees for years now. But I really don’t want to talk about exercise and determination.

Rather, let’s talk about Just Eat It, the image circulating on social media with that very phrase. This expression has crossed my mind—but not my lips—during many a patient session way before the creative graphic emerged. Yes, sometimes I’d like to shout out JUST EAT IT! (or even JUST EAT!), at times when rational discussion seems to get us nowhere. But that’s my emotional—and occasionally frustrated—response.

Personally, I struggle with the just part of the statement. Does it feel like a just to you, as an only? Or merely eat? To the person living with disordered eating, I bet just is the worst possible adverb imaginable. To me, it minimizes the struggle. Just eat it? As in, “it’s no big deal, what’s all the fuss about anyway”. EAT it?! If you could just eat, wouldn’t you?

The hike toward the Hornli Hut, heading toward
the Matterhorn.
My editor was reviewing this piece—by editor I mean husband—and he likened this minimizing to a personal experience he and I have had. You see, I have a fear of heights, and I swear it’s worsened as I’ve gotten older. So now, when we go hiking where the path has narrowed and I can vividly imagine the drop off to my death, I get a bit stuck—think deer-in-headlights kind of stuck. No, not just a bit stuck. There’ve been times when he’s had to talk me through, or physically be there to support me. At those times, he’s clearly communicated the message of “just do it, just get over it”, as in “what’s your problem?” failing to understand that my concern just might be irrational.

No, others really may not get it; fear is often irrational. But somehow reading a draft of this post he did get it. I don’t choose to get anxious at precipitous drops at high elevations. And sometimes the dangers are real. But the risk of stepping outside of your comfort zone to eat (as opposed to the risk of not eating enough), is not life threatening.

I suspect that if you really think about it, you’d realize that you used to eat the very foods you fear will make you fat, or will trigger overeating, with no ill effect. Think back to the time before the rigid rules and diets began, before your eating disorder or disordered relationship with food developed. Sure, you may associate carb restriction with something positive—weight loss perhaps (strictly because it resulted in reduced calories, and not because there’s anything magical about reducing carbs, or fats, or any food or nutrient in particular). 

But you fail to acknowledge that your struggle with binge eating only began with this restriction, with the deprivation. Or, that starting to restrict set you on your path to being unable to nourish your body, to respond to its needs. You hold on to all the ‘good’ you associate with dieting, yet minimize the consequences of your disordered eating on your health—on your mood, on your ability to be social, on your energy level, on your thinking.

There’s a bit of a conundrum we face; by we I mean providers and parents and loved ones alike. I can present all kinds of justification for nourishment—for including carbs, for increasing necessary calories, for adding snacks, whatever—but sometimes that’s not enough. Evidence that food restriction is slowing metabolism may help—such as pointing out that a slowed heart rate or lowered body temperature is a consequence of starvation. Showing evidence that you had previously been both healthy and a normal weight when eating your now feared foods may help, but it doesn’t seal the deal. 

Do you know which are the least read of all these blog posts? They are the ones describing research—the clearest evidence—in favor of normalizing your eating. Few tend to care about the evidence.
No, you can’t always negotiate with an eating disorder.

Sure, it’s easier if you know you can trust me—that I’m not going to mislead you; that it’ll really be okay if you make the dietary changes I suggest. But where’s the proof? Until you actually do it, and see that it really is okay, it’s challenging to trust. You believe that you’re different, that the rules simply don’t apply. And so we’re stuck.

At that point, you need a leap of faith. You need to go on blind faith that it will be okay. It helps to acknowledge that where you’re currently at is clearly not alright—in fact, that you’re quite miserable, if you allow yourself to be honest about how you feel. And it helps if you consider ‘what’s the worst that can happen?’ acknowledging that fear of rapid weight change is a distortion of your thinking; progress on so many levels can start here. Recognize that you don’t have to commit to continuing with this change forever—take it one day at a time, and give yourself the opportunity to back out.

It can be scary getting to the top, but it's worth the effort.
Capu Rosso, Corsica
Sometimes we do need to “Eat it!” or “Do it” giving yourself no option but to not go running, or to cease all purge behaviors, for instance. Sometimes giving your self no option makes the recovery process much easier.

But if you can’t bring yourself to take that leap of faith, or to “Do it”, then eating disorder programs may be the next best thing. Or, for those living at home with family, FBT (family based treatment for eating disorders) may be a great alternative.

Over time, you’ll realize that there’s really no other option for living a healthy life than to maintain the changes you’ve started.
Just saying.

What are your thoughts? Is anyone reading out there?

Saturday, December 14, 2013

Coming Clean: My Biases and What They Mean for You

I’m no different than the rest of you. I too, have my biases—my prejudices, my leanings, my preconceived ideas about what makes sense. They influence my actions, my reading of scientific studies, and they impact my professional recommendations.

I make no apologies; my biases effect what I tell you as patients and as blog readers. Like conference speakers obliged to disclose who profits from their research or their words, I’m giving my full disclosure. Here are some insights about why I lean as I do:

1) I’m biased against the weight loss literature's conclusions. In spite of the dismal research that only a small percentage of overweight dieters maintain their weight loss, I’m biased against these results. Weight loss, and maintenance is not an unreasonable goal—for some people, that is. Yes, I realize that the weight suppression data may suggest otherwise, as mentioned in my previous post.

Yet I’m skeptical about how study participants lost the reported weight and that impact on weight regain. And I’m cautious about who should have been losing in the first place. If someone had been binge eating and normalized their eating, why wouldn’t they lose weight and keep it off—as long as they remained free of binge eating? If you were disconnected from your physical cues, from your hunger and your fullness, but then turned that around, why couldn’t you maintain the lost weight? That is, if your higher weight was not your healthy normal that you had always been. Which gets me to the next point.

Many patients have appropriately lost and maintained significant weight loss. They were not on diet plans—not calorie counting, no categorical exclusions such as “no white flour” or “no carbs”. Rather, they have slowly modified their actions, and their thoughts. And ultimately, their weight adjusted. Read about my patients such as Erin and Maggie.

I fit into the category above. I have lost about 35 pounds since graduating from college—35 pounds that were not a part of my usual size. My weight had always been in the normal range—I had never experienced weight issues until college, when my yo-yoing began. Dieting, binging, denial of my needs failed to bring my weight back to normal. But changing all that did. I do not work to maintain my weight at this point, but I continually embrace honoring what I feel like eating, and responding to when I need to eat.

2) I believe that you know best about yourself—until your disordered thoughts, your restrictive rules, your lack of trust in yourself take over. Yet I believe that deep down you really know just how much you need to eat—just like when you were a young child before all this craziness began. It’s just so damn scary!

3) I’m biased against light products and diet packaged meals. No, they are not simply better than not eating (shout out to Thursday's patient—thanks for inspiring this!) Why? Because they mislead you! Tricky Weight Watcher’s meals and Lean Cuisines? Sneaky Arnold rounds? Indeed. 

First, they may look like they’re supposed to be enough. The light bread (that has half the calories than the regular bread) looks like a full sandwich. But then when you’re hungry from eating what amounts to only half a sandwich, whom do you blame? You only fault yourself, believing that it should’ve been enough, that you’re the one with the problem. Not so, my friends!

As for the frozen meals, I must say that in all my (50) years I’ve never eaten a diet frozen dinner, so my bias does not come from my experience having them. They just look like not enough to me—or for anyone. Admittedly, you can add a glass of milk, and a fruit or a dessert and it may be just fine. But somehow I don’t suspect that’s what you intend to do.

4) I’m biased against omitting what we enjoy eating. I believe that sweets and all things that taste good have a place in our diet. Maybe it’s because I personally eat things I like, including baked goods and good chocolate quite frequently. Excessively? Mindlessly? Not usually. Not when I’m driving or watching TV. Ok, sometimes the popcorn comes down to the family room (notice how passive that statement was?) while I’m watching TV—there, I’ve said it. Maybe it’s because I see the consequence of banning them, of making them forbidden, that I fight for making them available.

5) Yes, I’m biased against eating disorders.  Eating disorders lie. Which is not to say you are a liar. Have you lost me yet? They distort what you perceive you’ve eaten—yes, you overestimate your calories if you are under eating, and you may minimize or exaggerate them if you overate—it can go either way. 

Eating disorders mislead you into thinking that a yogurt is a meal, or that a black coffee, or even a latte is an appropriate means to respond to your hunger. They don’t volunteer information—I have to ask, and beg and probe to get a full and honest response.

6) It’s not your fault—again, that’s my bias. I don’t believe you want to be struggling with binge eating, or purging, compulsive exercise or laxative abuse or restrictive eating. And I’m convinced that I, that we can’t simply wait around until you’re simply ready.

7) I’m suspect when I only hear that everything is always great. And I’m cynical when I hear that everything is always terrible. Your bias, I suspect, is a lack of honesty with yourself.

8) I’m partial to the value of the relationship. I’ve not reviewed the literature on this, but my bias is that you’re more likely to work to change—at least initially—for your soon-to-be-born child or for your young children. And if you’re fortunate enough to have a positive relationship with a healthcare provider, you’ll work for them too.

9) Oh, and regardless of what they tell you, I believe it’s never too late to change. And this bias is based on the many clients I’ve seen, at all ages, at all stages of their disordered relationship with food. Yes, you too can recover from an eating disorder. And you can change your relationship with food. Even now.

So call me biased.

Friday, December 6, 2013

Self-parenting and your relationship with food.

Because you’re more than just dust and ashes.

How long could you have stayed in bed
with this look?
I was lying in bed contemplating this long overdue post, when he started to whine. “I’ll be up soon, go lie down”, I barked to my canine. If he really needed to go out or to eat, I knew I’d hear from him again soon. And so he hunkered down, curling up comfortably in his bed. And I scored one in an attempt to get my needs met, namely more desperately needed sleep.

Only my head was too filled with other things. There’s this post to write, for instance, and food shopping to do, household chores, and… So my need for sleep was bypassed.

And what does this have to do with you?

Get a little help from your friends.
Most of you, it seems, struggle with meeting your needs or are dependent on others to realize your needs. But I don’t mean simply your nutrient needs.

Regardless of your age, you need parenting of sorts. Or call it nurturing. And compassion. And validation. And if you no longer have parents, or your parents don’t rise to the occasion to provide these necessary supports, then you need to find them elsewhere—from your friends, your community, your providers. And you need to provide them for yourself.

Where’s the compassion? 

Can’t we treat ourselves they way we wish others would have treated us? Can’t we say things to ourselves like the supportive words we say (or wish we would say) to our close friends and loved ones? Consider this:

“A person should have two pieces of paper, one in each pocket, to be used as necessary. On one of them [is written] ‘The world was created for me,’ and on the other, ‘I am dust and ashes.’” 
–Reb Simhah Bunim, Przysucha Poland, (1765-1827)
You just might need to give yourself a hug.
I’ve always loved this saying, which emphasizes the need to be neither too haughty and self important nor to minimize your value in the world. The problem, though, is that most clients I see struggling with eating issues err on the side of focusing on the ‘dust and ashes’.

Must you, must we, dismiss the positives, focusing only on our failures? You are not just making excuses seeking to justify your behaviors, when you acknowledge your positives. Understanding informs you where you need to go next, where the barriers need to be broken.

Where’s your voice? 

I realize I have little experience with this one, as I learned a style of communicating that perhaps errs on the side of over vocal. I know, I know, filtering has its benefits. But keeping your thoughts and feelings inside does nothing to aid your relationship with food. It festers (I love this word), defined as eats away, gnaws away, putrefies, becomes infected).

Sure, you can plan what you’re going to eat, and you may follow through. You can organize your eating, and that surely helps. But failing to release those pent up thoughts and feelings only contributes to your struggle with food. Because overeating or food restriction—yes either one—can feel like the antibiotic that remedies the problem. Only the disorder has become resistant to this so-called antibiotic, and is ineffective as a long-term treatment.

The way I see it, communicating is a necessary component of recovery. But if you aren’t yet up for speaking your thoughts, at least express them—through journaling, music or art. Be creative—there’s not a right way to release what you are holding inside.
Not even aware of what you’re feeling? Just starting the creative process may make you aware. Or maybe you need one of these to identify your emotions.

Where’s the self-acceptance? 

Self-acceptance doesn’t mean staying stuck. It isn’t synonymous with accepting that you just can’t change the way things are. Rather, it means accepting what’s in your hands to change and knowing when you need to gather the supports to help you move on. It means setting realistic goals given the trauma work you’re doing, or the crises at home or the multiple hats you’re wearing day-to-day. It means appreciating even a gradual move in a healthier direction, versus viewing your progress as all or nothing.

He's got me at last.And we both really need it.
I think I’ll go snuggle with my dog now. He needs it. And I could use it too on this rainy, dreary day. The laundry and shopping will just have to wait.

Saturday, November 23, 2013

My Struggle With Obesity.

Warning: you just may not like this post!

Gorgeous, no? Barnes Museum, Philadelphia
I must admit, I’ve been conflicted about obesity. “Why conflicted”, you may ask? “What’s to debate? If you’re fat or overweight you should get down to the normal BMI”, right? Not so fast.

The two sides I struggle with

Diabetes and heart disease conferences bombard me with slides linking obesity with an increased risk of Type 2 diabetes. And I’m warned that obesity is the underlying problem responsible for our ills, including hypertension and even some cancers. For the record, I have had high blood pressure since my 20s as did my father—and no amount of weight loss with our in range BMIs would have been appropriate to lower our risk. So I have my biases when it comes to making assumptions about disease and body weight.
The focus on weight loss is unrelenting. Doctors, for instance, will often refer their diabetic patients to me, pounding them with the message that it’s all about their weight. Sure, weight loss may improve their levels. But simply modifying aspects of their intake, and their activity, regardless of weight change, can yield great improvements in blood sugar. Yes, regardless of whether they have had much shift on the scale. And we’ve become so focused on those darn BMI charts, using norms for the population as our targets, that we’ve failed to consider what normal truly is for the individual.

Good outcomes with minimal weight change

A recent diabetes webinar referenced a few large, well done studies about obesity, weight loss and development of type 2 diabetes. On average, a weight loss of only 7% was enough to reduce the risk of developing Type 2 diabetes by 50-68 %, in these 3 studies (one referenced above)! That’s right. If you are a 200 lb individual (regardless of your BMI), a 14 pound weight reduction can dramatically lower your chances of getting diabetes.
A 5-6 % to 10% loss in body weight in obese individuals significantly decreased BP in those with hypertension. That said, an even greater improvement was seen in those who also followed a diet high in fruits, vegetables, and low fat dairy products—consistent with the DASH diet for lowering blood pressure.
They’d still be considered obese, mind you. But that amount of weight loss may be just fine!

Why pushing for weight loss may be a bad idea

Recently, I attended a 2 hour presentation at the Renfrew (Eating Disorder) Center by a Dr. Lowe, from Drexel University, a researcher who studies weight suppression. Weight suppression  (WS) is the difference between your highest, non-pregnant, non-ill BMI and your current BMI. It was truly fascinating and in some ways depressing, what his and other studies show.
The degree of WS predicted many undesirable effects. CBT, the treatment strategy that engages your thoughts and feelings to change your actions, was less effective in those with greater WS. In addition, the impact of staying at a lower BMI (lower than your historically normal BMI) doubled the rate of binge eating (although this was not seen in some other studies). Higher weight suppression predicted worsened symptoms, including depression and ED psychopathology in anorexic patients, too. In ‘weight restored’ AN individuals who do not resume menstruation, there was a correlation with higher WS; even though they were at healthy BMIs (based on population norms) at program discharge, their normal-by-the-population-based-BMI-charts were not necessarily healthy and normal for them!
Larger sized, and beautiful. Seemingly content, too.
Residual symptoms in those we view as ‘weight recovered’ may be a red flag indicating that weight may further need to increase. I know, I know, this is not what you hoped hear.
Also of note, (and also depressing), is the data on pre-eating-disorder weights, even in young kids (think elementary school and up). Before their eating disorder, those who went on to develop anorexia or bulimia were at higher weights than their peers. Maybe healthy and appropriate for them—just higher.
In other words, pushing your body to get to or to maintain a less than ideal weight for you based on your history may add to your risk of getting an eating disorder, will increase your odds of being unable to use well-known strategies to change your thinking and actions, and is associated with more subsequent weight regain.
The Fat Nutritionist also gives a great summary of why it’s a constant battle to lose weight in her recent post Why Diets Don't Work.
If you struggle with bulimia, and have not had significant weight suppression, your weight may possibly drop as behaviors improve.
Are you confused now? Do you question whether your actions can really make a difference? Or frustrated that you are hopelessly unhealthy, given your obesity?

So where am I at in this debate?

We come in all varieties--& we are not all at the 50% percentile for weight!
I know all too well that modifying lifestyle factors can both improve your health and support weight loss and well being, in those who are overweight. I have witnessed significant weight loss—up to 150 lbs.—with a high degree of weight suppression—that has been maintained over many years in my patients. Perhaps the weight suppression data isn’t looking at weight loss via mindfulness and healthy lifestyle changes, but rather just focuses on absolute weight shift? That may be true for some studies.
But I have also seen some patients do all the right things while their weight stayed steady. Which leads me to this: if you are doing your part—eating mindfully and listening to your body, staying (or getting active), and you’re not losing weight, then the answer is simple: you shouldn’t torture yourself. You are doing what’s in your hands to do, to keep your risk low and to be fit and healthy—in spite of the population-based links between weight and disease. So don’t let these study summaries bring you down!

Being responsible for change. A case in point

A recent experience when I was traveling leads me to clarify my position on weight change. I was eating dinner in a remote town in Washington state, far from the foodie finds in the not so distant Seattle and Vancouver cities. To set the scene, let me describe: the place was a dive, to the point that my husband selected a deep fried entree figuring that that was the greatest assurance that any contamination would be killed. There was a salad bar—but it looked like week-old decay ready for the compost. If we weren't so hungry, there's no way we would have stayed. But there was truly nothing else around.
A family walked in. Dad, a very large mom, and a very large school-aged girl, dressed in a snug-fitting cheerleading uniform.  And here's what I observed. The girl wanted to order the steak tips and vegetables, but was urged to get the cheeseburger and fries platter—it was cheaper. The dinner came with the salad bar, so she chose from the limited options—a fruit salad and sad looking iceberg, with creamy dressing. And she ordered a large soda—it just might’ve been part of the package deal.
From my limited observation of her and her family, (admittedly being in the booth behind them, I overheard much of their conversation), they have frequent meals out, and rely on hunting season to put food on the table seasonally. Food insecurity might play a role in their decision to pack in the calories when the price is right at the diner. Her parents’ role modeled consumption of large sodas and desserts in addition to calorie rich entrees. And from what I heard, cooking wasn’t something that the missus had any inclination to do. So eating in might have been no healthier than a frozen pizza and a regular soda.
Some things just might need to change.
It was quite enlightening, this uninhibited overeating which was seemingly the norm for this family. Seeing this, I would be foolish to believe that the young girl’s large size was solely due to genetics, uninfluenced by her environment and limited alternatives.
Perhaps when she gets older she may decide to shift her lifestyle—if she has the financial means to do so. But changing behaviors and patterns is quite a process. In the meanwhile, she may suffer the bullying of weight stigma and the weight yo-yoing consequences of fad diets. Perhaps the impact of her weight will make team sports too challenging to partake in—kids can be cruel. So in the end, her activity may decrease as she continues on her path, living in her current environment.
She may embark on many attempts to lose weight when she is a bit older, each attempt leaving her more despairing as the weight regain exceeds weight loss, in spite of her good intentions to restrict her intake and lose weight.
Or she may have success modifying her eating behaviors and physical activity in a sustainable way. She might learn to cook healthier balanced meals, and eat out less frequently. Perhaps she’ll learn to trust that the food will still be there, that she can stop when she’s eaten enough. Addressing eating behaviors—separating eating from distraction and distinguishing physical need for fuel from all the other reasons we eat—may result in significant weight change. I see this in my patients, and I’ve written about a couple of them in past posts. 
But don’t look at her at 25 or 30 years old with scorn and disgust—she is not to blame for her situation and your sneers will do nothing to better her situation.
And let me restate what I wrote in the Cupid post about kids and BMI. If a child is high on the charts, but gaining each year like any other healthy child, they may be just fine—if their behaviors are appropriate. But if they are sedentary, or spending too many screen time hours, or eating in front of the TV, or eating minimal amounts of fruits and vegetables, and low fat dairy, for instance, then yes, I would address those behaviors. And you know what? I’d suggest the very same thing if I saw an average weight child, too.

Final words

Rethink being the 'skinny girl'.
So think again about your idealized goal weight. If you’re a normal weight by the standard BMI, but you deny your hunger and restrain your eating, then weight gain may be the key to release the hold of your disorder. And if you are overweight or obese and have been adhering to healthy eating behaviors and physical activity, staying where you’re at—even though you remain many pounds from your goal weight—may be just what you need.
And if you haven’t changed anything and maintain unhealthy eating habits, some weight loss may result from more healthy behaviors. Modest change may be enough to improve your health measures, even if your weight remains in the obese range.
Pushing yourself by denying your body’s signals and its history will only create harm. You will struggle with your thoughts and your weight will likely climb as a rebound to over restriction.

There’s no simple answer. Significant weight loss has its risks. And staying at a high weight without addressing lifestyle factors also places you at risk. But focusing on healthy behaviors may be the most reasonable solution.
Please feel free to debrief after this lengthy post! As always, I care what you have to say, so do leave a comment!