Good food, bad food and calorie counting? What kids really need to learn.

Nutrition education in schools worries me. My sentiments have been echoed

on the Academy for Eating Disorders list serve and among peers from SCAN--the Academy for Nutrition and Dietetics (AND) subgroup populated by progressive thinkers.

A very different path.

To change the direction of how kids are being taught, I've written this piece. Share this locally, in your schools, and virtually. Use it, and use it fully, including my name, please. Thanks for spreading the word and working for change.

Good food, bad food and calorie counting? What kids really need to learn.

By Lori Lieberman, RD, MPH, CDE, LDN

In an attempt to tackle the “obesity epidemic” kids, educators and parents often receive well-intentioned but potentially harmful messages to manage eating. (1)Calorie-counting apps and black and white messages about what’s healthy to eat can be problematic. Kids, parents and educators need practical, realistic strategies to add to their toolbox. Help kids learn to self-regulate their food intake utilizing current knowledge on eating behaviors and the food environment and know the damage of deprivation-based diet approaches.

One size does not fit all!

We are educating the masses—kids of all sizes and weights, including those who are sedentary and those with very high needs given their size, needs for growth and for sports—and kids with personality traits who tend to be very literal, anxious or perfectionistic. Consequentially, food messages should be presented to serve all without harm.

Good food/bad food

Nutrition messages need to shift from the ineffective ‘good’ versus ‘bad’ nutrients and foods, to factors that impact the ability to self-regulate intake. Directing individuals to restrict their fat intake can backfire. (2) Labeling sugar as ‘bad’ and setting calorie budgets fails to control weight in long term. (3) Evidence shows that perceiving a scarcity of food and deprivation from restrained eating creates greater problems (4) and contributes to eating disorder development. (5)

Calorie counting 

Calorie counting is ineffective in the long run and conflicts with utilizing hunger and fullness—essential for managing energy balance. It fails to teach kids about major obstacles to changing eating—eating behaviors and environment. Counting calories has little positive impact on improving eating habits and weight. (3,6,7)In one study kids who began dieting had a significantly higher likelihood of developing a serious eating disorder. (5)

Portions 

Portions are also not one-size fits all. Current materials (1) refer to appropriate snack sizes but for underweight kids, competitive athletes, and those simply with higher needs, these may be inadequate. Many teens require more than the current campaign’s recommended single serving of most snacks and greater than the 100 calories encouraged as ‘moderate’.

Sit, structure, separate, sense. 

Let’s shift the focus to what works—a mindfulness approach addressing simple, achievable eating behaviors. (8,9)

Address these key behaviors to improve intake and portioning of food, applicable to all children and adults.

• Sit in the kitchen or designated eating space, at a table or counter when eating.
• Structure the day to include 3 balanced meals and snacks. Include an early breakfast and be prepared—keep snacks available and give kids a chance to eat when they need to. Encourage delaying not forbidding ‘seconds’, allowing time to sense fullness. Allow eating later when hunger is present.
• Separate eating from distractions, like TV, phone, homework, computer; distracted eating increases intake. Separate food from sight; keep food off the counters to prevent triggering eating.
• Separate food from its package! 
• Plate it.
• Use your senses. 
• See, smell, feel, hear and taste your food—whether it’s a cookie or cantaloupe. You’ll be more satisfied when you really pay attention to and enjoy what you’re eating.

Encourage positive additions and messages to support a healthy diet.

• Include 3 or more cups of milk, yogurt or milk alternative (such as soy milk) for protein, calcium and vitamin D.
• Choose fruit frequently. 
• Select from fresh, frozen, canned in juice. Don’t forget dried fruit—a convenient, satisfying, nutrient and fiber rich snack.
• Vary the Vegetables: shred them, steam them, sauté them, dip them, puree them into soups or smoothies. 
• Get them in all colors. Include more than a cup a day.
• Get real! Choose more foods that are processed less, including nuts and seeds, beans, whole grains and fresh fish/meats.

Let’s spread a sensible, more sensitive message to promote health among school age kids of various sizes and needs. Advocate for diversity of foods to normalize intake for a diet rich in nutrients and adequate in calories. Let’s focus on learning to encourage portions that fit the individual’s needs by integrating both mindfulness and environmental strategies. And let’s accept that normal eating includes having foods at times simply because they taste good.

Citations

1.http://www.fda.gov/Food/IngredientsPackagingLabeling/LabelingNutrition/ucm281746.htm

2. Wansink, Brian, and Pierre Chandon. Can “low-fat” nutrition labels lead to obesity? .Journal of marketing research 43.4 (2006): 605-617.

3. Lowe MR, Doshi SD, Katterman SN, Feig EH. Dieting and restrained eating as prospective predictors of weight gain. Frontiers in Psychology 2013;4:577.

4. Mullainathan, S, Shafir, E. Scarcity.New York::Times Books, 20135. Lowe, M. R., Thomas, J. G., Safer, D. L. and Butryn, M. L. (2007), The relationship of weight suppression and dietary restraint to binge eating in bulimia nervosa. Int. J. Eat. Disord., 40: 640–644. doi: 10.1002/eat.204056.

6. Downs, Julie S., et al. "Supplementing menu labeling with calorie recommendations to test for facilitation effects." American journal of public health 103.9 (2013): 1604-1609.

7. Ely, Alice V., et al. "Differential reward response to palatable food cues in past and current dieters: A fMRI study." Obesity 22.5 (2014): E38-E45.

8. Beshara, Monica, Amanda D.Hutchinson, and Carlene Wilson. "Does mindfulness matter? Everyday mindfulness, mindful eating and self-reported serving size of energy dense foods among a sample of South Australian adults." Appetite 67 (2013): 25-29

9. http://www.nutritionj.com/content/10/1/9  Supporting Intuitive eating section, Linda Bacon

What doctors must know about eating disorders.

I want your input. I need to hear your voices. For EDAW 2015, I have volunteered to present to two medical residency programs—one in Boston, MA and one in Providence, RI on what doctors need to know about eating disorders.  I've incorporated recommendations from twitter responders and from Aspire, but I welcome more input. Here's what I have to share with new doctors so far:

• Avoid the ‘Don’t ask, don’t tell’ approach. Patients rarely volunteer behaviors they feel ashamed of—bingeing, purging, diet pill and laxative abuse.  So providers need to ask. Nicely. Casually. Non-judgmentally. Include basic ED screening questions at routine visits.

• Early action is not just for college admissions. Eating disorders are best identified early and treated promptly. We wouldn’t simply wait it out to see if blood sugars simply turn around in a patient with type 1 diabetes. Take eating disorders as seriously as you would cancer, or

  

  The time is now for improving medical management
  of eating disorders.

  diabetes, or heart disease. Because like these medical conditions, they cause physical damage, and impact emotional wellbeing. And did I mention that left untreated they can be fatal?
• Relying on size is a seismic mistake. People of all sizes suffer from eating disorders. And because eating disorders in those of “normal” weight are often missed, they may be more chronic and challenging to overcome. Patients with anorexia can have high BMIs; they severely restrict their intake, are ruled by food rules and fear weight gain; their restriction impacts their ability to function, their mood, their blood pressure, body temperature, blood counts and thyroid level, fertility, bone density, and GI function.
• ED sufferers want help. People with eating disorders ultimately want to be free of their disorder. They are not just being difficult. They may also be struggling with depression, anxiety and OCD making recovery more challenging. They are
  
  suffering with their symptoms making day-to-day life unbearable. In fact, the risk of suicide is higher in those living with eating disorders and is a major cause of death in this population.
• Be careful what you ask for. Before recommending that your ‘overweight’ patients lose weight, do some assessing.  Has their weight or weight percentile been normal for them? What behaviors might be better addressed versus focusing on their weight? Diets can be the tipping point, precipitating an eating disorder. Striving to achieve and maintain a lower than usual weight contributes to maintenance of eating disorders.

  

  You can't simply tell by appearance that
  someone is suffering.

• Guys (yes even straight guys) get eating disorders. Seemingly healthy, fit, guys, and overweight boys and men live with eating disorders. Like girls and women, they may restrict and be fearful of gaining, binge eat, purge, and compulsively over exercise. EDs have no gender limits.
• Eating disorders may start in preadolescence, or at age 20, or in the 40s.  Eating disorders don’t expire when kids reach adulthood, or when adults mature. Individuals with EDs may first present for care after decades living with their ED or may have a late adult onset during a transition period in late adult hood.
• Read between the lines and ask the right questions. Please don’t praise a patient’s weight loss. Would you say great job if they lost due to cancer? Do focus on reinforcing healthy actions, not numbers. Rather, ask:
•  "What kinds of changes have you made?" 
• "How do you feel?" 
• "What percentage of your thoughts are spent thinking about food and eating?"
• "How’s your energy level?" 
• "How are you managing with these changes?"And note that healthy eaters are not always so healthy. Ask why your patient became a vegetarian/vegan. Why are they following a gluten-free or low carb diet?

Families play a critical role in
supporting a child's recovery.

• Parents are necessary supports for recovery. Overwhelmingly, parents need to be brought in to assist recovery. And the only thing we can blame parents for when it comes to eating disorders is their genes. 
• Eating disorders are serious mental health conditions. They have genetic, environmental and nutritional underpinnings. They don’t just “run their course” or become “out grown”. They require treatment by experienced providers. ASAP. Waiting may be lethal.
• If you don’t know, please ask! Check out AEDs medical resource guide and this. Seek out providers to collaborate with who are part of national or regional eating disorder organizations like AED, NEDA, iaedp and MEDA.

Please share this with your medical providers. And with your friends. And twitter followers. And with your Facebook friends.

Eating disorders require education and a break from the commonly help practices and beliefs. And you can help make it happen.

Thanks again to those who have already shared their ideas that were incorporated into this post.

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 experiment.com website https://experiment.com/projects/long-term-outcome-of-women-with-purging-disorder/Here 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