Saturday, September 27, 2014

Don't wait for an earthquake to shake you into action.

I was talking to a guy from San Francisco this week, and the subject turned to earthquakes. This long-time SF resident and survivor of the big quake of 1989 offered some very practical advice for me to share with my son, a San Francisco newbie, fortunately na├»ve about the seriousness of going through an earthquake. His focus was not on what to do during the crisis—although that advice is critical as well—but rather what to do before hand. How to be prepared for this challenging situation, because being prepared, as he put it, is the surest way to increase survival.

Imagine that while sitting and discussing such matters my mind moved to you, my dear readers. No, there’s no need to worry about earthquakes for most of you. Rather, the subject of preparedness as a means to ensure survival and minimize damage struck me as most fitting—whether you struggle with an eating disorder or living free of diet rules.

Have a plan, he said. In San Francisco that might mean knowing which are the secure places to hover—the solid doorways and tables to stay under. But before it strikes, he emphasized that it’s critical to have an action plan: to keep cash on hand—because you never know when you’ll need it and ATM machines simply don’t work in these situations. Have a plan for communicating with those you’re close with—because electric doorbells to apartment buildings will fail and telephone lines other than landlines will fail. A transistor radio helps you connect with the world—to reality check what’s going on outside of your own limited space. You’ll need light of course—so batteries and flashlights need to be stashed to access easily.  And of course a supply of non-perishable food as well as water. Decision-making when undernourished will surely be compromised.

Time to come out of hiding and ask for what you need.
You can guess where I’m going with this. Yes, the analogy applies to you who are metaphorically on no greater solid ground. Communication is key to survival, and planning for opening these channels is critical. Can you tell your partner you’re struggling? Can you ask for help shopping and cooking to ensure your health and nourishment? Can you simply say “I need a place to eat dinner tonight?” Can you ask them to keep the pastries off the counter when you are trying to avoid impulse eating? Can you ask for a referral to a therapist or a behaviorally oriented dietician?

Where’s your transistor radio, so to speak, your exposure to the world outside of your own thoughts? Admittedly the cultural media may not be the most fitting reality check for sane thoughts, for diet-free messages, unfortunately. What I mean is that you need exposure outside of your own disorder thoughts—someone that can ground you when you are limited inside your own space. Were you really happier when you were so much thinner? Did staying on that crazy diet truly improve your quality of life? Your mental health? Or are you using magical thinking like the way we recall old boyfriends/relationships, fantasizing about how awesome it all was--when really it was nothing of the sort? Do you think you’ll restrict just for now and then be able to simply normalize your eating? Think again!

Do you have a grounding place to run to—your doctor, therapist, dietician, perhaps even a higher level of care—if your foundation is shaking? Do you have ready to eat food for when resources are tough to come by? A reserve for when, due to all the stress, your ability to organize and think through what’s best to eat may be impaired?

Where will your light come from when the power goes out? Do you recharge with talk therapy, or maybe yoga or meditation? Do you get spiritual support or guidance from wise friends or loved ones?
You may get no warning before the quake, before the shake up to your healthy behaviors and thoughts. So have a plan. Be prepared.

What steps will you take? Please share—we can all use to hear some ideas!

Read more about slips and relapses:

Sunday, September 7, 2014

It's your mom's fault? Words and genes: what we can do about eating disorders

It's all your mother's fault.
Really, it's about lack of approval from your dad.
If you're a boy or a man, it must mean you're gay.
If you aren't underweight you certainly don't have anorexia.
As long as you're eating healthy foods, you're okay.
It's simply a choice.
Once you've had it, you'll never truly recover.
It's all about appearance and weight.
You have to be ready to recover.

True statements? Not at all. These commonly held misbeliefs about eating disorders do only harm. They minimize the complexity of eating disorders and the struggle of those suffering with anorexia, bulimia, and binge eating disorder. 

They prejudice everyone from those living with an eating disorder, to providers treating those they may or may not know have eating disorders. 

They lay guilt on parents who may be among the best supports for their kids in recovery, as evidenced by the FBT model. 

They stereotype people based on weight--as if BMI alone determines severity of eating disorders! My normal weight patients who subsist on 400 calories surely know better. As do those of my disordered obese patients who have struggled with size discrimination for most of their lives and are no less free of obsessive thoughts, patterns of severe food restriction and symptoms of starvation. Yes, weight, size and appearance mislead.

And if we wait until someone is "ready" to recover, it just might be too late. Yet just these past weeks I've heard that this was the guidance conveyed by a therapist 'treating' a patient with an eating disorder--"you've got to wait until you're ready" they were foolishly advised; no, undernourished people don't tend to make the wisest and healthiest decisions. That's right up there with the wisdom of the cardiologists who recently minimized the very serious risk of severely restricting intake; suggesting no need for worry because Sara was not actively purging (simply overexercising and restricting) or that Dan's low heart rate must just be a result of being an athlete (a starved one, that is, with a low metabolic rate).

Yes, there is work to be done.

Eating disorders need science, not stigma

Here's yet another brilliant idea from Cate Sangster (the first I'm familiar with is her suggestion for an eating disorder recovery cookbook, which we created to great acclaim--food to eat). This time, in recovery, Cate puts her social media savvy and creative thinking to great use with this ice bucket alternative to help us get answers about eating disorders. Like Cate, I support Dr. Cynthia Bulik's move to create a genetic database to better understand eating disorders, and the organization, Charlotte's Helix which was created to help make it happen. In the US, check out this link to ANGI to donate. Please check out the resources on this site as well, to arm you with correct information about eating disorders.

"Learn From Genes, Not Jeans, About Eating Disorders."
I have followed Cate's lead with my educating arm (pic on right), and encourage you all to do the same--and to donate $20 to Charlotte's Helix or ANGI or other worthy eating disorder organizations. Share your pics  on Twitter, Pinterest and Facebook, too! 

Saturday, August 9, 2014

Avoidance isn't the answer. It's time to bear hunt.

Recovery is a tricky thing. You may be making progress with your eating—whether you are working to overcome binge eating, anorexia or bulimia—but may be fooled into believing that you’ve truly normalized  your relationship with food. It may feel like you’ve largely recovered; you’ve started to include ice cream (but only when you’re out, never keeping it in the house). And your binge frequency is close to zero. And surely you who’ve been restricting deserve credit for eating more than you used to—at least of the foods you deem good for you.

But consider this:

No, avoidance isn't the answer.

  • Is it really recovery when the only way you feel in control is to fill your days with so much activity (no, not even physical activity) that you don't get to sit with your feelings? You work long hours waitressing, take on extra shifts or extend your work hours only to avoid being with yourself. You struggle to allow yourself to feel hungry—fearing you're not trustworthy to respond correctly. You equally fear fullness, that satisfying feeling of truly getting enough. Would you allow your best friend to carry on this way?
  • Is it really recovery when you stop binging, only to restrict your food intake? You stick around family or friends because you know you'd never binge in their presence, but you also struggle to eat enough when they're around—and even when they’re not. If your child see-sawed between binge eating and restricting her food intake, would you say “that's just fine”?
It doesn't have to be so scary.
  • Is it truly changing your relationship with food when your solution for managing chocolate cake—or your favorite flavor ice cream or bread or peanut butter—is to simply never have it around? You forbid yourself access—just for now, until you meet your weight goal, or maybe believing you’ll resist these for the rest of your life. Would you suggest this to your parent, or would you hope that life could be much better for them?
  • Are you really recovering when the only way to nourish yourself (yes, I know some of you struggle with this loaded expression which implies self care in its fullest sense) is by keeping everything the same, limiting your food choices to just a few "safe" foods? Or, by weighing and measuring all of your food? No, not just for now, but forever? What would you say to your partner if he or she kept to the same restricted allowance, an even number of items to be comfortably ritually consumed, day after day after day?
Time to start living again.
  • How normal is your eating if you rely on counting your calories, or your points a la weight watchers? Or if you can't release yourself from exercising when your intake exceeds your ideal or your self-prescribed amount?

Can you truly recover? Absolutely!

Full recovery requires feeling—not avoidance of hunger and fullness. Detaching yourself from these physical sensations, like avoidance of all feelings—sadness, disappointment, fear, hopelessness—only prolongs your suffering (while admittedly for a moment it seems like the only way to get through). Avoiding feeling by numbing out with your eating or your not eating, serves a purpose. But let’s not forget that you lose out on life’s positive emotions and experiences, too.

It requires “Going on a bear hunt” so to speak—a reference to Rosen and Oxenbury’s children’s book I loved to read when my kids were very young.

"We're going to catch a big one. / What a beautiful day! / We're not scared. / Oh-oh! Grass! / Long, wavy grass. / We can't go over it. / We can't go under it. / Oh, no! / We've got to go through it!" The family skids down a grassy slope, swishes across a river, sludges through mud and, of course, finally sees the bear…”

It takes trudging through all the uncomfortable challenges—with support, of course—in order to get past your fears. Like the very young kids, you might (at first) run away when you face the bear. But with some work (perhaps there needs to be a part 2 to this classic), you’ll be embracing it and feeling all the better for it.

There’s more to life than yearning for foods you enjoy yet avoid, or regretting the little you did eat. Or struggling after a binge—an inevitable consequence of days, weeks or a lifetime of rigid diet rules, of avoiding eating enough.

You deserve better. Really you do.  I don’t mean to minimize any progress you’ve made. I simply want to urge caution to be on guard for those sneaky eating disordered thoughts and actions. So please consider reaching out to take the next step to push through—to change your thoughts, your feelings and your eating. Push through the tall grasses and the mud. And conquer the bear.

Oh, and please share your thoughts with us!


Saturday, July 26, 2014

Want to know how much I ate today? The pros and cons of comparing your eating to others’

Today's breakfast-crepes with sauteed fruit,
melted chocolate drizzle and vanilla yogurt.
When I was little, I mean, when I was young, (I was never particularly little compared to my peers), I recall a recurrent argument with my mother. “She can have it/eat it/do it—so why can’t I?”, I’d beg to know, to which she’d respond something like “If she jumps off the Empire State building does that make it okay for you too?” (Yes, I’m from NY and that was the tallest building back then.) Her point, of course, was that what’s good for one isn’t necessarily good for another. And if you’re going to compare, be careful.

Which gets me to you and your need to compare yourself to others; and more specifically, to compare your eating and your weight.  So what do you think—helpful to compare or harmful? Is it okay sometimes, or must you be consistent and never compare? Does it matter if you’re under eating, or if you’re overweight or is it simply dangerous?

Does it really matter what I eat (or anyone else, for that matter)?

Well, yes. To be honest, that’s why I include all the so-called food porn on this blog—beautiful images of delectable foods—all of which I am personally eating. Perhaps it shouldn’t matter. I mean I can give you sensible guidance regardless of how I choose to eat. But knowing that someone else is eating cookies or including carbs, or adding fats—things you just might fear—and is perfectly fine, reassures us. Viewing a peer’s eating as they’re comfortably eating ice cream can help motivate. Yes, normal, healthy people can and do eat ice cream. Seeing this can help increase your flexibility around foods and food categories—and that surely can help you change your relationship with food.

Yet it’s rather unprofessional to suggest that because something is fine for me that it’s fine for you. When I make my recommendations, they are based on my clinical experience—my 28 years in the nutrition field—and my knowledge of nutritional science and the limited research we have to work with.  What’s fine for me, isn’t necessarily right for you; I might include lots of veggies daily, but for you that added volume might be a challenge, making it difficult to meet your calorie needs. I might make most snacks rather calorie rich—when I’m out cycling or hiking for many hours and I’d rather eat smaller portions at each snack for convenience—this may be unnecessary for you; I’m almost 5’8 and my weight is just fine where it is, but your needs may be different—based on your height, your bone structure, your muscle mass, perhaps from years as an athlete, and your needs to normalize your weight to support your health.

Be careful!

My lunch. Looks big, right? Two pitas 'cause they were those too-light-be-
adequate 80-calorie ones. Certainly larger appearing than my husband's!*
When comparing to others, you might think—“She’s only eating a salad, why is that not okay for me?” or “Why do I need to work out when none of my coworkers do?” You may look at a friend and wonder how they can eat whatever they like when you have to be more mindful, or else your weight climbs out of your healthy range with no effort. Patients get frustrated when they report that their coworkers eat fast food and “junk food” and their weight is just fine, whereas they have to work hard and watch everything they eat. But they aren’t with these coworkers 24/7. Who knows what happens the rest of the time. What you see is a small slice of time, which may or may not reflect how any individual really eats.
Maybe they eat lighter when others are around—but make up for it in private. Perhaps they eat more only when they’re out with friends like you, but restrict when they are alone. Essentially, you have no idea what really goes on when you’re not with them. Unless I asked (and unless he were honest), I’d have no idea that my husband eats the leftover baked goods from work functions when he gets hungry and hasn’t brought enough to eat from home. Or even if he has, yet they are sitting so attractively frosted and displayed in work common areas for all to grab.

What you observe others eat may not be in their best interest—nor in yours. They may be struggling, denying their hunger and feeling fatigue, and preoccupied with food all the time.

He looks sedentary, but you should've seen him run today!
Are you comparing yourself to others for the wrong reasons? Do you let your eating disorder do the comparing as in “She’s having the fries, but I’m going to just order the side salad” or “He’s ordering the large ice cream, so I’ll just get the kiddie sized one.” Not what I’d recommend!

But I’m different

Do you ever think “that’s fine for you, but my body’s different”? You’re not alone! Somehow you may struggle to believe that what’s true for everyone else—that they can eat a range of nutrients including fats and protein and carbohydrate and no foods need be absolutely forbidden—just doesn’t apply to you. In fact, this basic truth does apply! Take a look at this older post:

My FAVorite cupcake place--located in NYC.

There are dangers in comparing your eating with others, as one size does not fit all. Just like food labels should not dictate how much we should be consuming—they merely identify nutrition info—you need to learn just what will meet your body’s individual needs.
And just because they decide to put themselves at risk and jump from the Empire State building doesn’t mean it’s okay for you.

* And for the record, I had a Napoleon pastry late afternoon and take out Japanese for dinner--with some nice Chardonnay. And if you asked, I'd tell you there were a few other items, too.

Please share your thoughts and let me know you’re out there reading!

Friday, July 4, 2014

Declare Your Freedom: Gaining independence from diets and disorders.

This stormy day, oppressed by the weather and the limits on my freedom to enjoy the outside, I find myself home, contemplating your freedom. It’s July 4, a national holiday in these united states.  Fortunate to have been born in the US, never oppressed by my government, I take for granted the freedoms that some yearn for. Yet through my day to day interaction with patients, I’m painfully aware of how enslaved many are by their own thoughts and actions—though admittedly not by their choosing. Most wish not to suffer, but feel entrapped; they are overwhelmed by the rules which dictate what’s acceptable to eat and the intrusive thoughts and judgments about their eating and activity. They irrationally fear anything from white flour and sugar to fats. Sometimes the type of foods is not the issue, but the portions are. At first glance, a food record may look impressively normal—until I probe about quantities consumed—the limited bites here and pieces there that are actually consumed.

“We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness…”

While this preamble to the Declaration paves the way to addressing national independence, it’s predicated on individual rights.  Yet how many of you acknowledge these basic entitlements?

Equality. Do you feel that your needs should be considered equally with those around you? Do you consider your needs—for time for yourself, for eating when you need to and what you feel like? Do you feel deserving of pleasurable dining experiences? Or is such pleasure only for other people to experience?

Life. A full and satisfying life. Yes, you are deserving of this too. A healthy life, allowing you to engage in whatever you enjoy. A life not eaten up by self criticism.

Liberty. Freedom from food rules (barring medically critical ones, like avoidance of an allergen that causes a reaction). And liberation from mental hoops you jump through whenever you consider food and eating. Must you feel guilty if something tastes ‘too good’?

The pursuit of happiness. Can you even imagine what this is? Do you remember what you were passionate about before food and diets snatched it all away? What do you dream about when you free yourself from the bitterness of your diets, of your restrictions, of your unrealistic expectations for size?

Freedom can be scary. But independence from both diets and disorders is the sure way to support life, liberty and the pursuit of happiness. I don’t think it’s simple. But taking a stand for change is a valuable first step.Seek out supports--an experienced therapist, dietitian and medical provider can help. But also use your close connections--don't be afraid to ask loved ones for help. Become informed--there's a wealth of posts on this blog on nutrition realities and great links to other reputable bloggers and websites, as well as my books, drop the diet and food to eat, coauthored with ASPIRE's founder, Cate Sangster.

What steps will you take to declare your independence?

Thursday, June 26, 2014

Exercise: Enough or too much? Knowing when to change gears.

Are you exercising enough or too much? Do you feel you need to be doing more? It’s often hard to judge for yourself. So take a look at these cases, modified from patients I encountered this past month, and see what you think:

Regardless of the activity, do be sure to listen to your body's needs!
  • A competitive skier, who spends 5 hours/day skiing and 90 minutes/day hiking;
  • A college student who runs 30 minutes, 4-5 times/week;
  • A biker who biked 55 miles one day, 107 miles over 3 days;
  • A coach who worked out at the gym 6 days/week, and spends 12 hour days physically active coaching.
  • A woman with anorexia who runs 3-4 days/week for 40 minutes.

If you’re thinking: “It depends”, you’re right. So here are some more details:

  • The skier came to see me wanting to gain weight to improve her strength and performance. She was fully on board with gaining weight and with eating more.
  • The college runner? He pushes the intensity and distance when he’s overeaten or binged and then also overcompensates by eating less.
  • The woman with anorexia? She has been successfully cutting down from her daily, injury-inducing hour-plus runs, while simultaneously increasing her food intake.
  • The sports coach? His activity stays constant regardless of his intake. And his intake hovers between 300 and 400 calories per day. And his weight is stable.
  • As for the biker? That’s me. I’m not making excuses but my husband got us lost on a ride last Sunday and we did way more than planned in our training for a 150 mile fundraising ride; but I did need to get the training in and was planning on a 40 miler. Along the route, after a full breakfast I had a delicious scone—and a generous lunch out. I acknowledged my poor planning when I petitioned my husband to part with one of his bars. He gave in and I ate it, and I was quite thankful.

Now what do you think? Is it becoming clearer?

It’s difficult to fairly evaluate activity levels simply by knowing the type of activity and the duration—whether or not you have an eating disorder or disordered eating. Without evaluating the bigger picture of thoughts and intentions, that is. The skier—with her very high activity but drive to eat enough for performance and health—is the least of my concerns—as long as her eating changes support her intentions. But the coach and the college runner? Activity is clearly used inappropriately in their cases.

But what if intentions are healthy—you want to maintain your healthy weight or even lose weight from your current higher than usual and healthy place, perhaps to include a moderate level of activity? Yes, I do support increased activity in these patients. With caution, though, in those with a history of eating disorders. And I support increased activity to help improve elevated blood sugars and cholesterol levels. But if you spend your waking hours premeditating how to work out to justify your eating, that’s a problem. If you perceive that it’s healthy to work out—for instance, you have intentions to be a healthy person—but your food intake falls short, resulting in low energy, irritability, early fatigue, inappropriate weight loss or slowed metabolic rate (with low body temp and heart rate)—then those good intentions clearly aren’t enough.

A healthy mind and body

Compelled to exercise at midnight because you can’t sit with the cookies you ate? It’s not enough that your vital signs are stable or that your weight is “better than it used to be”. No, there’s a problem here. Obsessed with the calorie displays on the treadmill, or the number of steps or miles on your pedometer or FitBit? Maybe it’s time to rethink your activity.

From my clinical experience, I’ve seen more previously sedentary people give up moderate activity when their sole goal was dropping pounds. Patients who exercise strictly to manage their weight are challenged to maintain their activity. If they didn’t drop weight in spite of exercising, they think: “why bother”; they ignore all the positives like the sense of achievement in having followed through with their goal, the improvement in mood and in sleep. They forget how nice it was to have time for themselves—or to connect with others around something other than eating. They fail to remind themselves about how their endurance or their strength has improved. So they drop the exercise.

Ok, I also ride to get to great places. Provence, France
I don’t ride to lose weight. I love the outdoors and love the feeling of the breeze on my face, like a dog with his snout poking through the car window. I like how it feels when I’ve accomplished a ride, but also how it feels while I’m riding; yes, I even like the journey. I enjoy the camaraderie of riding with company, but sometimes prefer to go off by myself. And my weight? It tends to remain within a couple of pounds throughout biking season. No doubt, because I am mindful to eat enough, stay strong while cycling—sometimes even when I don’t notice hunger. Sound crazy? There are times—like immediately after my ride or when we take a rest, that stomach hunger isn’t clear. Yet the fatigue might be stepping in, a sign of hunger gone too far, which can be resolved with nourishment. Sometimes the act of pushing fluids to stay well hydrated limits my perception of hunger. The high intake of water or Gatorade can buffer your hunger, making it more challenging to know that eating is necessary.

But if I did ride to support stabilizing a climbing weight, or to turn this trend around—would it be a problem? Perhaps not. Exercise, per se, is not the issue. But using it while denying adequate nourishment surely requires some help.

Back to my patients

Sure, the frequency and duration of activity might be a red flag, but we really need context to gauge its appropriateness.
The skier I have little concern about—in spite of her very high and frequent exercise—because it appears that her head is in the right place. And I was met with no resistance when encouraging practical calorie boosting recommendation to increase her energy and her weight.

For the coach with a very low calorie intake, his weight might be stable, but his intake is very restrictive. And he has a history of losing significant amounts of weight combined with unhealthy thoughts and behaviors—that’s a major problem. There should be no physical activity for him—at least until his intake increases significantly. Exercising, in his case, will only break down the muscle he has long worked to develop.

What are you hoping to achieve by working out?
The 30-minute college runner’s activity concerns me a great deal. Clearly it’s not the amount of exercise, but the way in which it’s used when he is uncomfortable sitting with the distress of eating, when he perceives he’s eaten too much. Yet I’m less worried about my patient running with anorexia—as long as she continues her progress with eating enough and maintaining her weight and medical stability—which she has done beautiful well with.
In some instances it’s quite clear that the exercise prescription needs be refined. If your weight or vital signs are falling out of range—something has to change, starting with reduction or elimination of activity; and if your eating becomes more restrictive, even if your weight is stable (due to slowed metabolic rate with undereating + exercising), activity needs to go. Really.

Many individuals can include exercise and be healthy—even if the exercise supports weight loss (in someone for whom weight loss is deemed appropriate by their medical team).

Talk to a therapist, your doctor, or your dietitian about your activity level. But don’t forget to share your thoughts—not just the details of duration, frequency and intensity of your activity.