Getting Personal: Lessons About GERD, Cancer, HAES, Bulima & Food Restriction

Read this if you are overweight. And read this if you purge through vomiting. Read this if you restrict your intake to less than you know your body needs. And read this if you've been told you have reflux, GERD or Barrett's esophagus.

Stomach--cow, not human, though!

I was recently contacted by a blogger colleague, aware of my Health At Every Size (HAES) philosophy from my blog writings. She was interested in referring a client for Medical Nutrition Therapy for reflux, with a history of Barrett's esophagus. For those of you not in the know, reflux, GERD or gastroesophageal reflux disease, is a condition where acid from the stomach comes up into the esophagus—that tube connecting your throat and your stomach—where it's not meant to be. 

Over time, that stomach acid starts to change the lining of the esophagus and cause inflammation, heartburn and discomfort. For about 5-15% of sufferers, the cells lining the esophagus begin to change, resulting in a condition called Barrett's esophagus. Barrett's esophagus can be well controlled with diet and medication, but in some cases progresses to esophageal cancer. By the time cancer is diagnosed in those patients, the cancer has invaded the area making the prognosis far from great.

My mother was diagnosed with adenocarcinoma—a cancer of the esophagus.

Now, back to the referrer. She wanted to be sure that I wouldn't focus on the client’s weight; because that's what people tend to do—just focus on the weight. What my fellow blogger was unaware of was that I was in the midst of struggling with the horrific consequences of this very common symptom, reflux, which ultimately led to cancer of the esophagus, a potentially preventable disease. And I am painfully aware of all the risk factors that contribute to esophageal cancer—including obesity. 

For most of my years, my mother popped Rolaids and Tums, those chewable antacids, like they were candy. She didn't binge, but she ate compulsively. She wasn't a drinker or a smoker—alcohol and smoking also add to the risk—but she couldn't part with her coffee which like most things acidic make things worse. And she was obese, a major risk factor for reflux. In fact, after her gastric bypass surgery, her reflux disappeared. For 8 years, in fact, she experienced little or no reflux. But it was too late; the damage was done.

Now if you're thinking you're not the intended target for this post, don't stop reading! My story, unfortunately, impacts the purgers among you as well as those dreadfully afraid to eat. So please keep reading.

While the verdict isn't in yet, there appears to be an increased risk of reflux, Barrett's esophagus and cancer, based on a study of studies, a meta analysis, on bulimics. This should come as no surprise, as acid going where it's not meant to go is what causes the problem. Fear may not drive you to change your behavior. But perhaps you haven't considered your risk of getting a potentially fatal cancer, right up there with dental issues and of course, sudden death, all consequences that you can prevent.

So where do you restrictors fit into this article?

Let me enlighten you a bit more about the treatment for esophageal cancer. The best hope for survival is to have surgery, after aggressive chemo and radiation. If you're a candidate for surgery, you're in luck. Well, sort of. The surgery requires removal of most or all of your esophagus and creation of a new pseudo-esophagus from your stomach. It's a seriously risky surgery, but can be done well by top surgeons. We were fortunate, and in fact, her past gastric bypass likely aided the situation, making it easier to use her already bypassed stomach remnant.

If you've long struggled with your weight—like my mother did—being told you have to take in many hundreds of calories a day doesn't sit too well. So any opportunity to stop the tube feeding (from which the bulk of nourishment comes during the initial and very critical weeks of healing), is taken. 

Yes, she restricted. The lack of significant weight loss convinced her that there was no issue with her minimal nourishment. Never mind that she became lethargic, spending most of her days in bed, barely able to walk. Or that she became depressed, or that her thinking was far from clear. (Yes, sometimes it's difficult to see the damage from restricting as it's happening.)

That's the state she was in this weekend when I visited. She had convinced the doctors by telephone that she was eating fine, and they were even considering removing her feeding tube tomorrow. 

Except that now she was readmitted and has a blood clot in her lung. I can't say why, these things do happen, but laying in bed fatigued from poor intake no doubt didn't help.

Back to HAES and my fellow blogger.

I fully understand the experience of the obese, being told that their weight is the cause of all evils—even the common cold! As an RD, I would never just focus on weight loss for someone with GERD. Rather, I would address symptom management with volume changes, and reduce acidic foods that aggravate the inflammation. I'd guide the patient on foods and meal content that might be contributing to the reflux.

But would I avoid discussion of weight loss in an obese patient, if their eating were excessive for their need, if they had been gaining weight? Or for that matter, if portion adjustments could be made, reducing both calories and stomach volume that would improve acid reflux, and also result in weight loss? Studies show an association, and that's not to say that all obese people need to lose weight. I get it.

That said, for those with GERD, losing weight tends to improve symptoms, and gaining weight tends to worsen them in obese individuals, especially in those with intra-abdominal obesity.  

Thanks for reading. Please do me a favor and share this with someone you know whose's at risk. Tweet it, blog about it, Facebook 'like' it or simply talk about it.

In Response to Bridal Hunger Games

Preventing the Damage After the Wedding

It's hard to know what disturbs me most about the NY Times article Bridal Hunger Games printed yesterday. Was it the hopelessness of women who don't fit into their ideal image of what a bride should look like—willing to take dietary change to extreme measures to achieve short term “success”? Or my fright at the willingness of MDs and nurses, helping health professionals, whose “first do no harm” mantra has clearly been dismissed? 


Or maybe it's the NY Times itself for creating a piece that seems more like an advertisement for unhealthy weight loss schemes, rather than a balanced report on the pitiful state of our culture and the consequences of being lured into quick weight loss schemes?

Pressure on women for their “big day” abounds, and it's been addressed before on this blog http://dropitandeat.blogspot.com/2011/09/wedding-diet-guaranteed-to-change-your.html. But let's take another look, from the perspective of the newlywed in her post-honeymoon period.

It's now October or November, some months past the glorious wedding day. And as quickly as it was lost using a  starvation strategy—NG tube or HCG, or self-imposed restrictive dieting—her weight has been climbing. Those lovely wedding photos are images of the past, as she is now left with a rapidly gaining yet non-pregnant body. With  her deprivation diet, she began to crave foods like never before. Her thoughts about food and eating were all consuming (pun not intended) and her rigid pattern of restricting has turned into rebound binge eating. 


The more she withholds the calories her body needs, the more she feels stuck in the cycle of overeating and over thinking. Her thoughts become more black and white, as she feels that once she starts, there's no stopping her. She feels hopeless and depressed. And she certainly doesn't want her disgusting body, as she sees it, to be touched. This is hardly the fairytale she envisioned.

In fairness, this certainly might have gone somewhat differently. Perhaps her predisposition to developing an eating disorder, combined with the trigger of dietary restriction and stress leads her to continue her weight loss. Now her periods become irregular and soon ultimately stop. Her libido drops and her irritability worsens, along with depression. She spends way too much time thinking about food and eating and exercise now, and becomes more withdrawn, avoiding social encounters. Hardly wedded bliss.

In either case, there is hope. Food intake can be normalized and health, both mental and physical, can be restored. But the best thing would have been prevention—avoidance of these crazy, unhealthy diets which can cause this whole scenario to snowball. So if you're lured into believing that you'll be happier dropping weight for your wedding day, please think again!

But back to the article and all my issues.

Where the Medical Community Goes Wrong

Ok, so apparently the nurse tells the patients about the FDA risks about the procedure. Great. But action speaks louder than words. If a provider wearing a lab coat tells you he/she does this all the time and promotes it as a solution to your problem, don't you think it's fine to do? Won't you allow your unhealthy, irrational thoughts to buy into the “treatment”, forgetting the risks? 


Who ARE these providers, willing to inject patients with a hormone while supporting extreme starvation of 500 calories per day, a deficit of at least 1000-1500 calories daily for most moderately active women of average height? Or those willing to subject healthy women to a feeding vehicle reserved for the severely ill unable to consume enough food orally—cancer patients, anorexics, to name a few—simply to make a buck? And the nerve to call it “nutritionally balanced” when it is devoid of carbohydrate, and induces ketosis and self-starvation! 

And yes, the quoted Dr. Shikora gets it right—but regrettably fails to acknowledge that discomfort is the least of the problem; he acknowledges with what I suspect is a bit of sarcasm that having a tube shoved down your nose is “not always comfortable and pleasant”—perhaps because he hears more complaints of discomfort following the gastric bypass surgery he is well-known for performing.

And while Dr. Aronne wisely suggests that waiting until there's little time left for change (resulting in taking extreme measures) is not the best strategy, I'm still left questioning this assumption:  that brides need to lose weight for their wedding! Perhaps if the focus were not on losing weight for a dress or for a day's appearance, I'd be okay. If weight had been climbing as the soon-to-be-bride had become sedentary or had turned to stress eating to manage at her new job, I could certainly see room for change. Addressing her unhealthy behaviors to help her gain control of her emotional overeating, to strategize about alternative coping measures, or to learn to distinguish hunger from other eating triggers—these I could support. 


Helping the soon-to-be-bride feel better, I certainly endorse. But that's not what the article encouraged. Maybe it's me, but this seemed like a sensational article about how to lose weight rapidly, without appropriately highlighting the very serious consequences.

So if you're feeling hopeless about your weight, don't be lured by promises of quick fixes—wedding, or no wedding. Consider the consequences of your actions both on your thinking and your general well being, not just on your weight now but in the future. 


And if you're ready to make changes, be sure they are reasonable to live with—not just for a week or two, but for life. No eating plan that severely restricts calories or omits whole food categories fits this description! 

Shame on these doctors who promote such weight loss programs. And shame on the NY Times for such an unbalanced perspective of the costs of such measures. You could easily buy a new dress at Kleinfeld's for the future cost of an eating disorder program, and the cost of your time at the therapist, doctor and dietitians' sessions to undo the damage from these diets. 


Fitting into your grandmother's dress, or society's expectation of your wedding day appearance, is no justification for messing with your head, and your body.

Erin hit 300 pounds Wednesday. And was she happy?

Ecstatic! She hit the 300lb. mark for the first time in more than two decades, and she was delighted. Her total weight loss came to 91 ¼ pounds since we started our work together. How did she do it, you ask?

Well, I could give you that simplistic response that many medical experts reply—“she just took in fewer calories than she was burning”. Oh, that answers it! That’s a statement of the obvious. But how did she really do it? I mean she presented to my office at almost 400 lbs. and at 5 ft. 1inch that’s a lot of extra weight to carry around.

First, she ignored her doctor. That is, when her doctor repeatedly hounded her that she should resolve her weight problem by getting gastric bypass or lap band surgery. Doctors love to recommend these treatments. Faced with a patient like Erin they are likely feeling quite useless and ineffective. No quick and easy solutions, as in “take these antibiotics and the infection will be gone in 48 hours.” They seem to see surgery as a quick fix, failing to see the challenges that patients face even afterward. No, bypass surgery doesn’t cure the problem, although it does help get some weight off in the very overweight and can improve some medical conditions including diabetes and hypertension. And for certain individuals it is something I would and do support.

But patients are left without the skills to manage their feelings and thoughts contributing to their pattern of overeating. That part doesn’t simply get rebooted or surgically removed. If you’ve always relied on food to self-sooth, to comfort, to numb out or simply to enjoy—to excess, you’ll continue to struggle with the very same issues, even after bypass surgery. And you’ll learn to work the system, so to speak. You’ll find ways to get your food “needs” met, with or without feeling ill—perhaps with milkshakes or other liquids spread throughout the day, perhaps enduring the “dumping syndrome” resulting in diarrhea, that follows.

Confronted with a problem that is complex and requires much time and patience, the wise doctors refer to me and others with my experience. And that’s how I came to meet Erin.

Erin could write a book on losing weight. She had been on all the conventional diets—the Weight Watchers, Jenny Craig, Diet Center types. And she had done the less conventional treatments as well, including the physician supervised protein sparing modified fast, under the direction of a leading obesity researcher at a Harvard teaching hospital. She had even attempted a more holistic approach at the highly regarded Mind Body Institute in the Boston area. These strategies were not without success. Erin would lose some weight, learn some skills, but fail to sustain the changes. Until now.

How do I know that this time is different? Because it’s been 19 years. No, she hadn’t seen me continuously for 19 years. Erin first came to see me in 1991 and has worked with me over long intervals, returning periodically as needed. And, it’s different this time because Erin has made some major changes that she hadn’t made in the past.

Like cooking. And shopping. As Erin found out, liquid diets and frozen meal plans are effective for weight loss. That is, if you’re looking for short-term weight loss. 


But nobody sticks to protein shakes or prepackaged food long term. Who can? Even if you love the taste, they don’t allow for living a normal life, for living in the real world. So what do you do when you are invited to someone’s home to eat? Or want to be social and eat out? Or take part in a celebration? Or not feel deprived? Ultimately, you have to learn to prepare foods, even if, like Erin, you didn’t even know how to boil rice. Or had never had a vegetable other than potato. And even if it’s “just you” at home.

So we started small. And basic. But Erin increased her confidence in cooking. Slowly. And she dramatically expanded the variety of foods she purchases and consumes. She now looks at her shopping cart with amazement. From asparagus, peppers, and broccoli slaw salads to brown rice and chicken soup ingredients. Her shopping cart does not look like what you might assume you’d see a 300-pound woman purchasing!

But Erin has not been without setbacks. Imagine experiencing this one. She has just gone shopping, at Trader Joe’s in fact, and has loaded the groceries in her car. She is now quite hungry, as things took longer than expected while she was out. Erin takes my recommendations to heart. So she realizes that the best thing to do is to honor her hunger, to have a snack to tide her over until she could get back home for lunch. She rummages through her paper bags and pulls out an individually portioned snack. And then proceeds to eat it, mindfully, while parked, in the Trader Joe’s parking lot in Hanover, Massachusetts. Until a woman approaches her car. Yes, a total stranger comes up to Erin's car and starts to lay into her about her eating. “Should you be eating that?” she demands. “You should really watch what you eat at your weight, it’s not good for your health”, she continues.

Could you even imagine how Erin felt? I was in tears listening to the abuse she endured, feeling the shame she experienced. And here she was doing all the right things—listening to her needs, her hunger, making wise choices (no, she didn’t manage her hunger at the drive through), eating mindfully, versus driving and eating as she had done so many times before. And yet in spite of all the good she was doing for herself some arrogant, unenlightened soul had the nerve to open her mouth and utter what she did. So yes, Erin had a slip that week.

But she also had a recovery. Her binge didn’t last as long as it had in the past and she was able to get back on her feet sooner than she had in the past. She didn’t get into the all or nothing thinking about her eating, thinking that she ruined it and may as well keep going. And she didn’t bury her feelings in her food late at night. Rather, she came in to talk about them in sessions with me and with her therapist. And as a result, the damage was kept to a minimum.

The struggle is far from over, and Erin has lots more weight to lose. Her latest goal? She wants to lose 8 ¾ pounds. Yes, just 8 ¾ pounds to bring her total weight loss to 100 pounds. That’s her short-term goal. Yes, Erin has learned something else through all this. She has learned to set realistic goals, goals she can achieve and maintain. And with her new pedometer, she plans to increase her activity one step at time.

Yes, Erin is thrilled to have hit 300!