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.

Fat and Always Hungry? No, cutting the carbs won't cure your weight struggle.

It’s 10 AM Sunday and quite frankly, I’d much prefer to be leisurely finishing my coffee after my blueberry pancakes-topped with a dollop of vanilla yogurt and heated real maple syrup. But Ludwig and Friedman’s Always Hungry? Here’s Why piece in the NY Times  today compelled me away from my plate.

To start, let’s get a title change, please, let’s say Here’s What We Think based on virtually no research at all. This is an opinion piece stating two doctors’ theories about why we get fat and what we should do about it. Period. But with the sensational image and title you, like most people, will be drawn into more myths about weight management.

Here’s where we agree—and disagree

Do you just eat bread for your meal?

Agree: There are factors outside of your control that may contribute to your size. Genetics and the presence of fat cells exert their influence. Once you have gained to a higher weight with an increase in fat cells, you will be fighting an uphill battle to lose that weight and keep it off—without disordered behaviors.  And it’s not your fault. For more on this see Professor Lowe’s work on weight suppression and bulimia. 

Agree: Metabolic rate slows down with food restriction—that’s indisputable from the research. Obese individuals who have undergone extreme low calorie diets will have a lower metabolic rate as a result of the decrease in muscle mass that results, compared to same weight controls who had not dieted. Less aggressive approaches to dietary activity change tend to spare the muscle loss and help maintain metabolic rate.

Before dieting...

But the authors state that metabolic rate also decreases with weight increase:  “…factors in the environment have triggered fat cells in our bodies to take in and store excessive amounts of glucose and other calorie-rich compounds. Since fewer calories are available to fuel metabolism, the brain tells the body to increase calorie intake (we feel hungry) and save energy (our metabolism slows down).” Yet there appears to be few examples of this cited in the scientific literature, with the exception of a possible rare genetic mutation, not likely the cause of obesity in the greater population.

And the temporary slowed metabolic rate seen with weight loss has been demonstrated to be reversed with weight restoration in the obese (albeit a small sample size studied) and more dramatically in those who are underweight with anorexia, summarized well by Carrie Arnold in ED Bites.  In practice we see dramatic increases in metabolic rate—calories burned and required each day—with weight gain in anorexic individuals at least until they have restored to their healthy state.

Agree: Insulin increases nutrient uptake and in excess causes weight gain. And carbohydrate results in an increase in insulin secretion.

Disagree: Ludwig and Friedman’s leap that foods that increase insulin secretion should therefore be reduced or avoided for weight management is faulty reasoning—unless there is a documented underlying metabolic abnormality. A relatively small percentage of the total population has PCOS or hyperinsulinemia—a faulty regulation of insulin. For these individuals, addressing carbohydrate amount or glycemic load (impact of a food on raising blood sugar) has a positive impact. But there’s no evidence that a low carbohydrate diet is any better at long-term weight management than any other dietary intervention. 

In addition, while individual foods and their glycemic index—the amount they raise blood sugar (and therefore subsequent insulin levels) may seem valuable, practically speaking they have less impact.  You see, we generally don’t eat single nutrients like carbohydrate. Rather, we eat mixed meals, containing protein, fat and carbohydrate. And in this combination, the impact on insulin levels that even the white potato might have if eaten solo is minimized with that piece of chicken and the added olive oil or nuts in the salad.

This banana chocolate pastry has plenty of fat to lower its glycemic load!
(From Tartine Bakery, San Francisco)

And did you know that many of the villainized desserts have a minimal impact on insulin levels? Peanut M&Ms aren’t much different than lentils (see glycemic load—the best measure of blood sugar impact which considers portion) and cheesecake made in it’s full fat recipe will no doubt come in quite low as well.

I don’t share this to promote a diet full of low nutrient, processed foods. Rather, to make a point. Viewing foods as good and bad will do nothing to help you manage your weight—nor your mental health. In fact, there’s plenty of evidence that feeling deprived by denying yourself foods you enjoy leads to rebound overeating.

The authors also state “what if it’s not overeating that causes us to get fat but the process of getting fatter that causes us to overeat? Unfortunately, I think they have oversimplified their hypothesis.

Sure, having more fat cells may contribute to our struggle if attempting to lose weight. But it’s not simply a macronutrient issue. Being larger presents more challenges for being active; larger individuals report being subjected to fat shaming while exercising—presenting its own challenges.

Rebound binge eating following starvation—think dieting—has been well documented as well. All or nothing thinking—what I call the “what the heck effect” results in overeating when you believe you’ve already blown it.

After...

Our over-scheduled lives with multiple competing needs don’t help us either. Multitasking while eating makes us less aware of what we are consuming and contributes to overeating. And the larger the containers or plates we are eating from, the more we will over-consume (see Prof.Wansink's extensive work on this).

Time and money constraints add flames to the fire—we take little time to plan, shop and eat mindfully. In fact, our cognitive ability is compromised by these stressors and worsened when we diet. Perceiving that we won’t have enough food to meet our wants or needs, referred to as scarcity creates a range of secondary effects. Poor decision making, impaired ability to organize and follow through and hyper-focusing on the immediate benefits without considering the long term consequences of food choices are well researched and described in the fascinating new book, Scarcity.

Unrealistic goals set by national organizations  and by ourselves adds to the problem. If 150 minutes per week plus 2 days of muscle strengthening/wk is unattainable, why bother?

Further, the food industry isn’t all bad. (And no, I am not a paid consultant to any food company!) They are the ones who bring us the convenience of precut and cleaned vegetables and canned, high fiber, low glycemic legumes. They allow us the convenience of reheating frozen brown rice and quick cook barley. And they have given us a range of milks in every fat percentage we could ask for, and yogurts of every style—Greek and higher protein, sweetened, full fat, real sugar, artificial sugar and no added sugar. But many of the choices remain ours.

So what’s the solution to our climbing weights beyond a healthy range?

• Move away from dieting and that sense of scarcity.
• Set realistic goals for change—be it frequency of a home-cooked meal or a visit to the gym.
• Begin to work on behaviors; separate eating from distractions, and delay seconds (see older posts on this blog for help)
• Include a range of foods and nutrients. Include high fiber, whole grains and legumes, fruits and vegetables, nuts and healthy oils; protein-rich foods such as poultry and fish, and less frequently red meat; low fat milk and yogurt and modest amounts of cheese.
• As part of a balanced meal, by all means enjoy your rice, breads and pasta, too. And you know my stand on baked goods! All or nothing approaches to dietary change will get you nowhere.

Thanks for reading and for passing this on via FB, Pinterest, Twitter...

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.

Priceless.

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!