Sunday, October 26, 2014

Start counting your calories boys and girls!

Should they start weighing and measuring
everything they eat?
This scares me. Really it does. The US government, the FDA more specifically, has decided to encourage kids and their educators and families—i.e. everyone—to start tracking their calories, because, you know, doesn’t that solve the ‘obesity epidemic’? Well, no, it doesn’t—and it may cause more harm than good.

Their stated goal is to get kids and families to start reading labels and think more about what and how much they eat. Innocent enough, right? Well I don’t think so. Maybe I’m biased because I see far too many kids and adults, stuck in their heads with too much information; they spend time calorie counting, and limit their choices to single portions of foods because that’s what the label says is the ‘right’ amount. They allow the label to define their personal need, as if serving size was one-size-fits-all, when really it’s designed to provide information about nutritional value per serving, based on “usual” portions. They’ve lost their intuitive sense of how to regulate their intake.

What’s wrong with this campaign?

Let’s start with the messages in this campaign, and then you decide how helpful the guidance is. Here are a few highlights, shown indented.

The end of childhood.
Keep track of the calories you eat throughout the day. To find out what your “target” calories per day are, visit .

Should kids really be tracking their calories, as if simply knowing their magic number would make everything all right? Calorie calculators are far from accurate, and don’t take into account a fair assessment of muscle mass which increases calorie requirement. They fail to adjust for individual variation in caloric need, aside for activity level. Larger sized body? You’ll get prompted with a CDC message that you’re at a high BMI and can choose to move to a ‘healthier’ weight—with no assessment of risk factors, and without regard to whether this has historically been a healthy place for you (based on your growth curves, if you’re a child, or your weight history, if you’re an adult).

I tried it out, for the sake of this piece. Where are the fats, I wondered? The sweets? Where’s the healthy, balanced diet? Exchanges from all food groups are included except for the oils and fats (fats may be components of foods in each category, but there was no place for added fats like healthy oils)despite acknowledging separately that they provide essential nutrients. 

They do identify a calorie level for what’s called empty calories—which I was pleased to seebut they don't include it as part of my daily meal plan! Surely they need to be included—because forbidding them will only lead to deprivation and preoccupation with getting them. Omitting them surely sends a message—that they are bad, and kids and adults will feel bad including them.

The impact on real kids

This might be just what Dan needs to meet his nutritional needs.
Dan decided to become a vegetarian last year, along with a family member because he cares about animals. Fine enough, as far as I’m concerned. But then his high school health teacher (using the FDA curriculum) directed him and his classmates—regardless of their size—to reduce their fat and sugar intake and choose foods lower in calories. You know, because of the ‘obesity epidemic’.

Problem is, Dan was thin from the start. And his intake was limited enough. And being tall, and active, resulted in inappropriate weight loss, during a time that weight gain is appropriate and necessary to support growth and development. Guidance from a respected figure like your high school teacher seems like a logical thing to follow—especially when it’s coming from the US government’s program.  Yet Dan is one of many, many kids I’ve seen negatively impacted by the direction of their health or science teacher.

Are you eating  just for calories?

Kids, like adults, eat for all kinds of reasons—because they’re stressed or anxious, because they’re tired, because they’re procrastinating getting their work done and because their friends are snacking, to name a few. Just telling them ‘here’s how much to eat’ fails to acknowledge the many obstacles to ‘Just doing it’. What if we taught them how to moderate portions and how to manage stress, arming them with alternative coping skills?

If you consume more calories than you burn, you gain weight.
I’m tired of weight gain being framed as a negative. Yes, they’ll gain weight! Isn’t that what growing kids are supposed to be doing?

400 calories or more per serving is high; 100 calories per serving is moderate
Yes, so what? The teenage athletes or kids in super growth modes might need closer to the high end than the low for calories per snack.

Consider stuffing a pita or wrapping a low-fat whole grain tortilla as a lower-fat alternative to some breads.
Why lower fat alternative? And how many breads are high fat anyway—unless we’re talking about croissants, which we don’t typically refer to as bread! And why pull out fat as a problem nutrient to be watched? There’s no shortage of evidence that low fat diets  have failed us in our attempt to control weight.

Read the Label to see which foods are lower in nutrients to get less of — then replace one high-fat or high-calorie item you would have ordered with one that has lower calories or fat.
Again, why villainize fats? Maybe portions to meet individual’s needs would be more appropriate to address.

Choose foods with less sugar.
For the record, you should know that a glass of milk—plain, unsweetened milk (yes, even organic and even more so fat free) contains a decent amount of sugar. Natural sugar, called lactose, that hasn’t been linked to disease development nor to obesity. And dried fruit? And fresh—if it had a label?  All are also high in sugar and need not be avoided. Perhaps this needs to be clarified in their materials.

Nuts and dried fruits can make great snacks because they often contain nutrients to get more of – as long as you follow the serving size!
Does that mean kids need to limit their portion to ¼ cup—even of their calorie needs are high?

Why this needs to change

I worry about the impact on our kids.
Dieting is one precipitator of eating disorders; a significant percentage of those struggling with an eating disorder started off with what seemed like an innocent diet. And we surely don’t need to increase this population.
Kids need enough calories to support growth. Weight loss is generally not indicated in kids.

General educators are not skilled enough to nuance the recommendations individually, and may have their own nutrition and diet baggage, so to speak. The teacher educating kids to calorie count who perhaps is also on Atkins is not the person I’d want influencing my children’s eating.
I certainly support nutrition education in schools. But I’d like to see a different type of education.

Imagine this

What if we taught this in schools instead? (adapted from Drop the Diet, Lieberman and Sangster link):

  • Eat breakfast within a half hour of waking.
  • Include 3 meals and 2-3 snacks daily, at a minimum. Avoid going more than 3 ½ - 4 hours without eating (during waking hours, of course).
  • Avoid compensating for a less-than-stellar day of eating; consider a clean slate, forgiving yourself for less-than-ideal eating.
  • Shut the TV and the electronics when eating, and work on eating mindfully. 
  • Keep all food in the kitchen—not the TV room, not the bedroom.
  • Use your senses; smell, see, feel, hear and taste your food, and truly enjoy eating.
  • Beware of false fullness from drinking lots of water or non-caloric beverages, or eating large volume of low calorie foods.
  • Ask yourself  “Am I hungry?” Consider other means to satisfy those other eating triggers when you aren’t hungry.
  • Clean up the environment. Keep foods off the counter to prevent them from calling to you. But eat foods you enjoy when you do need to eat. Then use the strategies above to manage portions.
As for the adults impacted by this campaign, be aware that at best, approximately 1 in 5 people who intentionally lose weight successfully keep it off for more than a year—and few studies track outcomes beyond this point. But maintaining lost weight should not be the sole measure of success. Weight suppression data identifies the risks that maintaining a weight below one’s highest weight creates.

Let’s not be short sighted and worsen one problem in an attempt to improve the health of our kids. There really is a better way.

Monday, October 13, 2014

The consequences of weight bias: beyond making you feel bad.

Debra came to me frustrated about her climbing weight, now about 20 pounds out of her normal range. This is nothing unusual for me—plenty of women and many men reach this point, desperate for answers and guidance to help them take charge of their weight. Others present for help managing symptoms or medical outcomes—like high blood pressure or cholesterol or GERD that have more to do with the quality of their diet than with their weight.

Debra was an active woman in her 50s, a non-emotional eater—yes, they do exist—who felt like she was doing most things right. She ate regular meals and snacks; she had to, as she started to feel really low energy, and fuzzy headed if she didn’t. And she’d start to get the sweats, too. She had a history of very high cholesterol, and a family history of Type 2 diabetes as well. And the weight she had previously maintained, her normal weight, was nothing crazy, nor did it require heroic measures to achieve it. Her goals were quite realistic.

After reviewing Debra’s intake and activity, I made modest recommendations to ensure she was doing whatever was reasonable in terms of change. Was she still getting the workout that she thought she was, or does she need to evaluate her intensity or duration? Perhaps with better conditioning she could prevent further weight gain. Was she inadvertently influenced by the halo effect—having more of those foods she believed to be healthy, such as lean protein sources or nuts—without an awareness of just how much was enough? ( Fullness was challenging to observe, she had stated. Perhaps she needed to evaluate just how much she needed as opposed to portioning her food on autopilot, without much attention to her need or While these recommendations were helpful—and prevented further weight gain—it was clear to me that another explanation was responsible. She had many markers for polycystic ovarian syndrome (PCOS) or hyperinsulinemia, a condition where high circulating levels of insulin result in symptoms of low blood sugar (including the sweats, fuzzy headedness, irritability and immediate need for food). (For more on hyperinsulinemia

At my suggestion, she went to see an endocrinologist—an MD appropriate for evaluating such conditions. From Debra’s report she shared her sense of despair about her climbing weight and belly fat, yet the doctor began to dismiss her, like all the overweight women who presented before her, with a simplistic, patronizing “Eat less and exercise more”. Yes, judgment was decreed without even listening to how high her activity already was and how appropriate her eating has consistently been. 

But once she added the comment about the symptoms between eating—those low blood sugar-type symptoms—he got it. He finally recognized that it was unfair to put the blame on her—to simply tell her she needs to exercise more or eat less because after all, weight management is about energy balance. He put her on metformin, which addresses the underlying issue—it’s an insulin sensitizer, so it helps prevent excess levels of circulating insulin.

The outcome? Most importantly, her symptoms stopped and she felt so much better. No more shakiness in between meals, and the sweats ceased, too. And, her weight dropped about 9 pounds over the past year, in contrast to the weight climb the preceding year that felt so out of her hands.

Weight bias in reverse

Another active woman—at a normal and stable weight, recently had a physical. She’s a 51 year old who enjoys food and eats a healthy diet. By healthy, I mean rich in healthy fats, whole grains, fruits and vegetables, with a reasonable intake of desserts and chocolate and wine. She’s not vegetarian—but her intake of meat is minimal—nor gluten free, nor dairy free, nor carb free. She’s a reliable reporter.  I know, because she is me! For the first time in her/my history, my cholesterol was high! The good cholesterol was high too—likely the result of my activity (I’d attribute it to genetics except neither parent had a high HDL)—but the bad, the LDL was out of any lab’s range of acceptable. Add that to my high blood pressure and that places me at further risk.

And what did my doctor do? Nothing. Other than telling me to continue to ‘watch my diet’ and maintain my activity (about which he knew little), that is. Yet the variables that I can control are already in order. My diet and exercise aren’t going to change for better so I don’t suspect there will be any astounding improvement. Most likely, my hormone status was likely the greatest factor increasing my levels—LDL can increase 15-25% with menopause! But heart disease risk similarly increases with postmenopausal elevations in cholesterol. 

Me (in Robin's hand-me-downs) and my slim father who had type 2 DM,
high blood pressure and high cholesterol
In spite of my high cholesterol, my doctor didn’t suggest that I have it rechecked in 3 months or that I start a statin to lower the levels. He didn't explore my exercise frequency, intensity or duration. While the updated 2014 cardiac risk calculator concludes statins for cholesterol lowering aren't necessary for me, (and doesn't include weight in the assessment) he didn't plug the numbers into this risk analyzer (I did later though.) No, I did not look like a high cholesterol patient so my cardiac risk was minimized.

I share this for those of you still blaming yourself—for your health, and for your weight. That is not to say that there aren’t things you can do to take charge of your health. Physical activity in moderate levels can improve insulin sensitivity, lower cholesterol, improve blood sugar and assist in energy balance. Oh, and it certainly may help mood and sleep, too. And eating portions appropriate for your need can help everything from reflux to fatigue to your weight climbing out of your normal, healthy range. Eating more home prepped meals can give you more control of portions and meal content. Even for you non-cooks, there are plenty of easy-to-prepare, yummy dishes you can make, with practical strategies for pulling it all together. And avoiding long periods without food certainly will improve your energy level and your control of eating when you finally take the time to eat.

But if you’re already doing what’s in your hands to do, don’t let others burden you with blame. And start to advocate for the care you deserve.

When I see my new doctor, you can bet I’ll be discussing my labs and inquiring about any treatments that might lower my risk. Because truly, my high cholesterol is not my fault.

thanks for reading!

Tuesday, October 7, 2014

Doing what we can to help eating disorders.

I don't know Jean Forney, a Phd student and AED (Academy for Eating Disorders) member studying eating disorders, but she has some very interesting ideas. She recently contacted me requesting I do a blog post on her research. Better yet, I thought--you can do it! I wasn't just passing the buck, but preferred to give her the opportunity to describe her proposal. 

One step in the right direction.
Measuring hormone levels to help predict eating disorder recovery (keep reading for the full description) is not simply about determining how long your eating disorder will last. It may offer insights about biological causes of eating disorders and ultimately to treatments for bulimia, binge eating disorder and purging disorder. 

I post this to offer hope--to show what young researchers are exploring to better understand eating disorders and help the path to recovery. And to offer you an opportunity to personally support the research (see her link at the end). 

The Importance of Physiological Research to Help Eating Disorder Treatment
By K. Jean Forney, M.S.

Eating is both a biological and psychological process. Deciding what to eat, when to eat, etc. - it’s governed by both our mind and our biological make-up. In trying to understand and treat eating disorders, more and more research is focusing on physiological processes to help supplement what we know about the role of the mind and psychological factors in eating disorders.
Two hormones involved in eating come to mind: cholecystokinin (CCK) and leptin. CCK is released from the gut during digestion. It sends a signal to the brain that says “Hey, I’m full!” and leads you to stop eating. Multiple studies have found that CCK is released more slowly in individuals with bulimia nervosa, an eating disorder characterized by binge eating and purging, compared to individuals without an eating disorder. In contrast, the CCK response appears to be normal in individuals with purging disorder, an eating disorder characterized by purging in the absence of binge eating. This led the authors who conducted the study to conclude that delayed CCK response is likely related to binge eating. 
Problematically, when you look at people at one point of time, you do not know if dysregulated CCK response occurred before the eating disorder started, or if it is a consequence of the eating disorder, or a combination of the two.  It also means that we do not know if a dysregulated CCK response makes someone more likely to binge eat and keeps the eating disorder perpetuating itself over time.
The other hormone I mentioned was leptin. Leptin is a hormone secreted from fat tissue. It is sometimes called an “adipostat” because it tells the body how much fat tissue it has. When leptin levels are too low, the brain is told to eat more via a network of neurons, neurotransmitters, and other hormones, and people become more hungry. Leptin levels appear to be lower in people with bulimia nervosa and purging disorder compared to people without eating disorders, and some authors have found that leptin levels are associated with duration of illness. That is, the lower the leptin levels, the longer someone has been ill. It makes you wonder if lower leptin somehow contributes to the eating disorder lasting longer, or if having an eating disorder causes lower leptin levels.
To answer that question, you need to study people at multiple time points.
I am running a study that will see how CCK and leptin levels predict eating disorder remission over time. Multiple women with bulimia nervosa and purging disorder have already participated in studies and had their CCK and leptin levels measured through blood draws. I will be interviewing these women, on average, 10 years after they had their blood drawn. Then, we will have some information as to whether or not these disruptions influence how likely someone is to recover from their eating disorder. This is part of a larger study looking at the long-term outcome of purging disorder and comparing it to bulimia nervosa.
Why does this matter? Well, the more we know about the processes that keep eating disorders going, the better interventions we can develop. Perhaps by treating both the body and the mind, we can help people have healthier, happier lives, free from the distress and impairment that eating disorders cause.

To read more about my study or to donate to help support the study, please see my website are some of the articles I gathered this information from, for your interest:
 Keel PK, Wolfe BE, Liddle RA, De Young KP, Jimerson DC. Clinical features and physiological response to a test meal in purging disorder and bulimia nervosa. Arch Gen Psychiatry. 2007;64(9):1058-1066. PMID: 17768271 Monteleone P, Martiadis V, Colurcio B, Maj M. Leptin secretion is related to chronicity and severity of the illness in bulimia nervosa. Psychosom Med. 2002;64(6):874-879. PMID: 12461192 Jimerson DC, Wolfe BE, Carroll DP, Keel PK. Psychobiology of purging disorder: Reduction in circulating leptin levels in purging disorder in comparison with controls. Int J Eat Disord. 2010;43(7):584-588. PMCID: 2891937
Expect another post from me soon!  And please share any thoughts about Jean's research here. Your voice really matters! Lori