Sunday, April 12, 2015

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 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.


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.  Supporting Intuitive eating section, Linda Bacon

Monday, February 23, 2015

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.

Monday, February 9, 2015

Why I’m worrying about Vyvanse and Binge Eating Disorder

Seeming quick fixes can be so tempting.
This week’s inbox held the following message from an old patient:

“I was watching Good Morning America and they had Monica Seles on, admitting she's suffered from binge eating disorder (BED). They announced a medication they are now using to treat BED, Vyvanse, also used for ADHD. I looked it up and side effects include weight loss. Have you ever recommended this drug for BED? Do you feel it is effective for BED? Can people with BED take this med to lose weight? Do they think if you have BED you must be overweight and this medication can cause weight loss? Which would perhaps (in their minds) solve the bingeing?

That small ED voice that lurks deep from within is screaming 'get me that drug! Get me that drug!' so I can lose weight. WTH?!"

I’m glad she was brave enough to share what she was wondering, as I’m sure she’s not alone in her curiosity. Aren’t you wondering what this means for you?

Let's start by clarifying a few things about binge eating disorder. Most notable about BED is the recurring episodes of binge eating, feeling out of control while binging, and feeling guilt and shame afterward. People of all sizes live with BED, and the experience of a binge may vary. You might eat large amounts of one itemsuch as a whole package of cookies—or large amounts from a combination of foods. For some, even eating a single bite beyond what they intended may feel like a binge.
There's a way off the roller coaster--appropriately
named the Cyclone.

The common features among sufferers, though, is the guilt, shame and lack of control accompanying the eating. According to the Binge Eating Disorder Association,  "Binge Eating Disorder (BED) is the most common eating disorder in the United States. An estimated 3.5% of women, 2% of men, and 30% to 40% of those seeking weight loss treatments can be clinically diagnosed with binge eating disorder. The disorder impacts people of all races, levels of education and income — including adults, children and adolescents."

Given the shame associated with BED, however, there are likely many more living with the condition than we know.

Medication to the rescue?

Two recent studies were done using Vyvanse—a stimulant used to treat ADHD—for the treatment of moderate to severe binge eating disorder. They were well-done studies— randomized, double-blind and placebo-controlled—with promising outcomes. 

In one study, participants who binged three or more times per week were treated with either a placebo—a dummy pill—or 30, 50 or 70 mgs/day. Researchers saw a significantly better response to the 50 and 70 mgs/day doses compared to placebo in a study of over 250 subjects with a roughly equal number of controls. Improvements included reduction in binge frequency/week, a higher percent of subjects binge free for 4 weeks, and a change from baseline in the Yale-Brown Obsessive Compulsive Scale Modified for Binge Eating—compared to placebo treatment.

Notable, however were a couple of other outcomes. The placebo group also improved, by 21.3 percent (versus 42% in the 50 mgs/day and 50% in the 70 mgs/day treated groups). Meaning, the belief that taking something could help your binge eating was enough to improve binge frequency.

And then there were the side effects. More than 5% of those treated with Vyvanse reported symptoms including “dry mouth, insomnia, headache, decreased appetite, nausea, irritability, heart rate increased, anxiety, feeling jittery, constipation, hyperhidrosis [excessive sweating].” Twelve patients (5%) on Vyvanse reported treatment-related adverse events that led them to stop the study; 5 patients in the placebo-treated group had such negative effects. 

And then there’s this: “CNS stimulants (amphetamines and methylphenidate-containing products) have a high potential for abuse and dependence.” 

If you struggle with Binge Eating Disorder and are tempted by the positive research results, consider the following before you request a prescription. While medications might improve binge eating, so does addressing some underlying eating patterns and thoughts—without the risks of medication. In fact, since the placebo also improved binge frequency by over 21%, it suggests that the power of believing you could change—with some help—is quite strong with BED.

Yes, there's hope without meds for BED!

Need I say more?

Do any of the following scenarios apply to you? If so, medications for BED may be unnecessary.
  1. You restrict your calories throughout the day, trying to be “good”. You deny your body the fuel it needs and by later in the day—often late afternoon or at night—you start eating, intending to eat in control. But then it feels like the flood gates open and you just can’t stop. Perhaps you feel like you’ve already blown it, so feeling defeated, you decide to continue to binge. You’re determined to get back on track tomorrow—with restricting. And so the cycle continues.
  2. You eat enough calories throughout the day, but your food choices are very limited—including only foods you "should" be eating based on rules you follow; they may be only high protein, or unprocessed or not very palatable. They are foods that you’re okay with, but that don’t necessarily give you much pleasure. Then, when at a friend’s or out to eat and you eat something to appear ‘normal’ or because you really want it, you have serious regret. Later you continue eating because you’ve already "ruined it", but are determined to get back to your very restrictive, healthy food choices.
  3. You truly get enough to eat—enough calories and enough of foods you really enjoy. But most of your eating is quite mindless—you eat standing up in the kitchen, while multitasking—while driving, on the computer or on the phone. So you never truly feel satisfied. And it’s worse when food is kept in sight.
  4. You eat enough, you get what you want to eat, AND you pay attention to eat mindfully. But when stress if high, or you struggle with an emotion that’s hard to sit with, your knee-jerk reaction is to reach for food for comfort or to numb out. You may even be completely aware of what you’re doing, but the pull is so strong, because in the short run, it helps. But later, you are left with regret.
If any of the above statements apply, then working with an eating disorder dietitian—together with a therapist can really help. Cognitive Behavioral Therapy (CBT) is a valuable, well-studied treatment for BED, and you can purchase self-help workbooks specifically for this condition as well. 

Learn to normalize  your eating!
Yes, binge eating can be resolved without medication. But it requires dropping the diet and rigidity around eating. Really, dieting simply isn't helping.

For those with ADHD who also binge eat, the medication may be helpful to manage impulsivity—which can lead to binge eating. Delayed gratification—redirecting and waiting to notice fullness—can be too challenging, as is moving away from multitasking.

But using Vyvanse is not without consequences. Decreased appetite may sound appealing but if you don’t know when you’re hungry, it's hard to trust when and how much to eat — making intuitive eating impossible. It may contribute to inadequate intake and food restriction—something those struggling with binge eating may already struggle with. 

Do we need to swap one problem with another?

Further, will doctors inappropriately start prescribing Vyvanse for those who are overweight but not living with moderate to severe BED? Will prescribing seem like the medical quick fix, while failing to address restrictive eating, or deprivation or over-exercising that truly need treatment? 

So, dear readers, please don’t be tempted. But don’t give up hope. Seek out providers that work with binge eating disorder patients because it is in your hands to change.

Other related links you might find helpful:

Saturday, January 10, 2015

Chocolate for fat people?!

Since I’ve last posted, I’ve had a troubling, food related conflict. Can I dump on you, dear readers? Can I model what I suggest you should do—to express yourselves and reach out for support?

Colleague conflict

I love good chocolate. So it follows that at holiday time I’d want to share the joy as holiday gifts to some providers that refer to my practice. (Remember, this dietitian has a cupcake as the mainpage image on her website. What harm in that, I thought?

Yet in sharing my intentions with a nutritionist colleague, I heard a very different perspective. Namely, that many office employees are trying to lose weight—so chocolates are the last thing they need. Those who are obese hardly need the box of chocolate sitting around the office. And since many are so anti-sugar these days, giving chocolates is simply a bad idea.

Once I moved from my totally speechless state (a rarity with me), I tried to be open-minded. Is it diet sabotage to give a box of chocolates to be eaten in an office with many employees—i.e. with little opportunity to squirrel them away, in the season of New Year’s weight loss goals? Was I sending the wrong message as a promoter of health, that chocolate—ok, they weren’t even exclusively heart-healthy 70% cacao-dark chocolates but simply great tasting Belgian chocolates—are an acceptable snack?

Further, can those of high BMIs be given chocolate (or cakes/cookies/highly-palatable foods)? Are they entitled to enjoy the pleasure of great tasting desserts? Should anyone, regardless of their size or percent body fat be given chocolates as gifts? I mean, should we even be allowed to eat foods we truly enjoy?

Must we live an ascetic life of food deprivation and denial—whether for short-term weight change or for life? Is that a healthy lifestyle? Are we doomed to live secret lives—the model kale-salad-protein-smoothie-ingester in public and guilt-laden, binge eater by night or by car ride?

Still on the fence?

Perhaps Jamie’s Christmas surprise will do the trick. This patient’s sorrow and shame was revisited in my office post holiday, as she described her Christmas disappointment. Her three siblings dug into their chocolate-filled stockings, while she rummaged through hers. Only hers was filled not with her favorite candies but with plastic items.  No chocolate indulgence for this overweight young woman. A helpful, healthy holiday message? I don’t think so. A supportive gesture? Hardly.

Let us not for a moment believe that we are not entitled to enjoy life’s simple food pleasures. Yes, you. Yes, regardless of your size.

For me, the conflict’s resolved.

And for you?