Diet Plan: Registered Dietitian

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Thứ Sáu, 31 tháng 5, 2013

Name-calling Has Its Place: BED is Now Named as a Distinct Eating Disorder. So what’s in it for you?

What’s in a name?

Perhaps it sounds like an existential question, but if it doesn’t have a name, does it even exist? Labeling Binge Eating Disorder (BED) what it is—a painful struggle living with frequent overeating large amounts of food—makes real the impact on mood, thoughts, energy level, physical wellbeing and hopelessness, to name a few.
Living with Binge Eating Disorder when it was not yet recognized as a diagnosis, you might not have felt sick enough or eligible to be treated, because it just wasn’t taken seriously enough by those around you.

Being added as a condition all its own validates this not-uncommon eating disorder whose sufferers live with their secret relationship with food, silently and ashamed.

Like adulterers you may sneak around family members and friends consuming large quantities of food—rarely lean protein or vegetables, I’ll add—but typically those foods and nutrients deemed forbidden. Yes, adulterers, as you carry on a relationship you may fail to acknowledge, cheating only yourself.

You eat quickly, masking the empty packages for fear of the response. “Who finished the cookies?” you dread hearing. You may eat salads or nothing at all in the workplace or with others, then stop at the convenience store or the fast food drive in and eat more than a day’s worth of calories, before even getting home. And then perhaps eat dinner as if nothing had ever happened. There may be a short-lived thrill preceding the binge, but a lingering guilt-filled regret to follow.

I should be mindfully eating?

Binge eaters rarely taste their food, nor do they enjoy it mindfully—from the accounts of my patients over the past 26 years. They eat cakes and cookies and ice cream, but they don’t consume them with permission—their own permission, that is. They may be quite unaware of what and how much they have eaten. And although there are exceptions, they rarely truly enjoy what they are binging on—although the experience may be quite pleasurable—in the short-term. Friday’s new patient diagnosed with BED would never come in for a follow up—that much was certain—if I dared to suggest he’d have to give up his nightly, longed for ritual of binge eating. Yes, making change takes time—and hard work.

Why oh why do I do this?

You may find yourself eating impulsively, wondering why, even though you know better, you can’t follow through with your intended control over food.

Let’s start with one basic fact. You are not stupid. It is not for lack of knowledge that you maintain your binge eating pattern, but likely because it meets some needs. It may temporarily numb you, a drug of choice for some, or may help manage your anxiety. Or it may be triggered by impulsivity, even greater in those who get too hungry and those who struggle with impulse control—like those with ADHD. Now don’t get me wrong. I’m not endorsing binge eating to meet your needs. Rather, hopefully providing some insight so you can begin to move from the place you are stuck.

Binge eating typically, although not always, follows deprivation and food restriction. Ever notice that your binging is worse after dieting or fearing you will be without food?

Thoughts like “I’ve already blown it so I may as well keep going”, what I call the what the heck effect, adds flames to the fire, contributing to continued overeating. Or you may preplan a binge—a very much-controlled binge, counter to the uncontrolled binges often described.

“What’s your point?”

I just sent a family member a link to a popular press article about a parallel situation- trichotillomania (compulsive hair pulling) is also now added to the new DSM-5, the mental health manual of diagnoses. In response to the link, the trich sufferer responded, “So what’s your point?” So let me clarify for all. The point is, if you are described in these posts, then you deserve to have your condition acknowledged and treated. And that includes getting support from a mental health professional (one who’s trained in CBT, Cognitive Behavioral Therapy). And for BED sufferers, adding a Registered Dietitian who specializes in eating disorders is essential as well.
It takes time to shift your eating pattern and your thoughts, and to find alternative ways to manage things that cause distress, but recovery is possible.

How do you change and move from being a binge eater? Five areas tend to need to be addressed. You’ll need to:

Eat enough calories throughout the day. Guidance from an RD can be quite helpful here.
Watch your eating pattern to avoid long periods without eating. Excessive hunger leads to excessive intake. Think about a pendulum; swinging to one extreme results in an equal swing in the opposite direction. We are looking to be swinging in a much more narrow range!
Move toward mindful eating. Start by separating eating from distractions, such as TV, reading, computer, driving, phone use. Keep food in the kitchen or dining room only. And try to use your senses when eating. Yes, you deserve to experience and taste what you eat.
Once you are preventing excessive hunger and mindfully eating, it’s time to reintroduce foods you view as ‘forbidden’. Remember that if you are listening to your hunger and eating when you need the fuel, you are no worse off for choosing something you really enjoy eating—be it ice cream or chocolate chip cookies. But keep in mind that while you’re working on liberalizing your ‘forbidden’ foods, work on…
Distinguishing physical hunger from emotional eating triggers, such as stress, reward, depression, anxiety, the need for self-punishment.

Now that it is a recognized condition, it’s my hope that MDs will no longer direct their overweight patients for lap band or gastric bypass surgery, never inquiring about or addressing the underlying problem behaviors. Perhaps the medical community will also begin to distinguish those who are overweight yet healthy—yes, they do co-exist—from those that are struggling with their thoughts and behaviors.

What I like most about this new diagnosis it that it puts the focus on your behavior, not your body weight. Now let’s hope that the medical community begins to ask the questions to open discussion about eating behaviors so that you and others can get the support and direction you need to recover.

Check out these older posts on binge eating and related themes:

Many more posts on the subject can be found by clicking on the relevant labels on the right of the blog.

I'd love to hear from you! Thanks for reading.

Thứ Ba, 26 tháng 2, 2013

What Registered Dietitians Believe: AKA Don’t Trust Everything You Read

Processed, white bread, with sweet, unsalted butter. Yum!

Yes, that’s white bread—homemade by my bread machine, in fact (with my husband’s assistance)—and that indeed is real butter on top, added by yours truly. It was part of my lunch, together with my favorite lentil soup. And, a piece of salted almond dark chocolate, along with a cup of tea I’m still sipping on. A reality program of what RDs really eat?Not quite. Rather, I’m compelled to respond to an article that makes showing up at dinner parties with my real identity as a Registered Dietitian quite challenging!

I stumbled upon 9 Ingredients Nutritionists Won’t Touch as it was retweeted by some RDs on Twitter. Exaggerated statements about foods that dietitians wouldn’t dare eat plastered the article, so I thought I'd clear the air for the sake of people like Brian (not his real name), a blog follower struggling with an eating disorder. He saw this Dietitian's response, which read “An irresponsible piece overgeneralizing about RDs and what is healthy! No soy protein? Only 100% whole grain bread? Really?” He responded “I used to assume all nutrition 'experts' were this rigid - & triggering. Hence I've never consulted any”.

So let me set you straight. This article certainly doesn't represent all dietitians. The hype suggesting we should never eat these 9 ingredients is crazy. No single ingredient moderately consumed is poison. Although I will admit that eating a hotdog every day will greatly increase your risk of cancer. And certainly no one food or ingredient causes weight gain. (Or weight loss. Sorry to disappoint you.) The reason why I'm taking the time to address this is because the last thing you need is more food rules—especially senseless ones.

Since I honestly have never been concerned enough to avoid at all costs the ingredients purported to be avoided by nutritionists, I needed to do a bit of research on these food concerns. With a little bit of digging, here’s what I conclude:

Corn oil and omega 6 fatty acids (FAs)

Sure, I'd recommend an increase in omega three fats from fish such as salmon, sardines, tuna (in moderation if you are in your childbearing years), flax and walnuts, to benefit from their role in reducing inflammation and lowering cardiac risk. But to set a rule that products with ingredients such as corn oil should be banned is unwarranted. Omega 6 FAs also have their benefits, and a focus on the ratio of omega-6 to omega 3s is apparently misguided. Read the experts' review http://circ.ahajournals.org/content/119/6/902.long

The cancer causing additive potassium benzoate and benzene

Here’s an excerpt from the 2009 FDA paper addressing concerns about benzene levels found in beverages: How many and what products were found to have excessive levels of benzene?:

To date, FDA has tested almost 200 soft drink and other beverages in the CFSAN survey. Benzene above 5 ppb was found in a total of ten products. Benzene above 5 ppb was found in nine of the beverage products that contain both added benzoate salts and ascorbic acid. FDA also found benzene above 5 ppb in one cranberry juice beverage with added ascorbic acid but no added benzoates (cranberries contain natural benzoates). The manufacturers have reformulated products, if still manufactured, which were identified in the survey as containing greater than 5 ppb benzene. CFSAN tested samples of these reformulated products and found that benzene levels were less than 1.5 ppb. See also Data on Benzene in Soft Drinks and Other Beverages, including product names and benzene levels.

Don't trust the FDA? Here's a balanced, unbiased piece from Livestrong, June 2011 which references additional sources, too.

Even though benzene levels are not an issue, I’d vote for moderate intake, at best, of sodas.

Soy is poison? This one I had to look up because I was clueless!

In the article on the nine ingredients we supposedly avoid like the plague, Nunez, the author quotes Valerie Berkowitz RD, saying "Soy protein, soy isolate, and soy oil are present in about 60 percent of the foods on the market and have been shown to impair fertility and affect estrogen in women, lower sex drive, and trigger puberty early in children," she says. "Soy can also add to the imbalance between omega-6 and omega-3 fatty acids." Unfortunately, the evidence simply isn’t there to support Berkowitz’s claim.

For a balanced review of the pros and cons of soy, check out this Huff Post piece http://www.huffingtonpost.com/neal-barnard-md/settling-the-soy-controve_b_453966.html, which, rather than sensationalizing food ingredients, cites the research from peer-reviewed journals that are considered state-of-the-art.

If you are still concerned about the unproven risks of GMO soy, that shouldn't stop you from choosing organic which eliminates this possible risk. Apparently organic soy is stated to be free not only of pesticides but of genetic modification.

As for palm oil? And processed foods?

My breakfast of smoked fish (with nitrites), enriched white
bread, and saturated-fat containing foods--in moderation, of course.

Sure, I'm not big on palm oil, a saturated fat, but again, it's about the bigger picture. How much are you consuming? Too much saturated fat will increase your LDL or “bad” cholesterol, as it's commonly known. But even those needing to follow a diet low in saturated fat to lower their high blood cholesterol levels can consume up to 7% of their total calories from saturated fat. Certainly that leaves room for the occasional product that has a bit of palm oil as an ingredient.

Nitrates and nitriteshave long been acknowledged to be carcinogenic, leading to cancer. So no, I wouldn't recommend frequent intake of hot dogs and bacon. But an occasional dog at a picnic? Be my guest.

The statement about avoiding enriched flour? That one tops the list as the most absurd recommendation, and the mere suggestion that this represents what dietitian's believe would certainly keep me from seeing one! So I'm with you, Brian. What they are suggesting is that enriched is code for refined—because the only foods that need enrichment are those that have been stripped of their original nutrients. That said, all foods do not need to be nutrient powerhouses; refined (unenriched bread) isn't poison, as part of a balanced diet. And of course enrichedbread would only bring additional B vitamins to the meal. So what's the problem? Must we always choose the most fiber filled, nutrient-rich food items? Can't we include vegetables for some of the fiber and vitamins and minerals, and simply enjoy the French bread—enriched or otherwise?

Articles like 9 Ingredientsperpetuate misinformation about food and nutrition and about dietitians. While it does refer to the nutrition professional as a nutritionist, a general term having no qualifications attached to it, they quoted from many a Registered Dietitian throughout the article.

If you're trying to improve your relationship with food and you visit with a Registered Dietitian whose messages match up with the 9 Ingredients hyped article, do run the other way! But please don't assume that we are all like that. I know I'm not alone in my approach to eating. Registered Dietitians with a focus on behavior change and those with extensive experience treating individuals with eating disorders are most likely to share my approach.

So Brian, hopefully now you’ll reconsider a visit to a dietitian—just find one with a sensible, balanced approach to eating.

Thanks for reading.

Thứ Ba, 30 tháng 10, 2012

Record Keeping to Change Your Perspective--And Your Eating

I'd LOVE to eat your food record, but I'm really not that hungry!

“My dog ate my food record.” “Oh, I left it at work.” “I know what I eat, I don’t need to write it down.” And finally, the very honest and most insightful comment I’ve heard, “I just couldn’t bring myself to do it. Because if I don't write it down, then maybe it didn't happen." This, perhaps, sums up why, in spite of knowing that food record keeping is recommended, it is often not done. But of course you know I can't just let it go at that!

First, let me clarify. A food record, generally speaking, is a journal of what you ate including the quantity of food, and when you ate it. A valuable food record also includes some other critical information—your perceived hunger when you begin eating, your thoughts and your feelings—both physical and emotional. Noting where you ate is also quite useful, as we’ll discuss in a bit. Oh, and if food was consumed but eating disorder behaviors followed, that should be noted as well.

And calories? In my view, these have no place in your food record. “But don’t they count and impact my weight?” Absolutely. Yet counting them is not my idea of a healthy way to change your relationship with food and normalize your weight. We are trying to get out of your head—away from your over-analyzing what's acceptable to eat—and into your body, aware of its signals to eat and to stop eating. A goal of record keeping is to help you learn to rely on these signals so you can trust your body—I know you're not there yet—but this is a great way to start.

Why all the fuss about keeping a food record? Why do Dietitians like me recommend it and why do so many struggle against doing it?

Accountability, compassion and shifting perspective

If you know that someone is going to be looking, you certainly think twice about what you eat. Now you may think that you already are painfully aware of what others think about your eating. And that recording only makes you obsess more about what you're eating. But writing it down in the way described below does something different. It allows you not to hyper focus on the meal you overate or the fact that you ate when you think you didn't need to. Rather it allows you to look at the bigger picture. Truthfully, this is where having another set of experienced eyes makes all the difference.

Just saw this in NYC--can you imagine?!

Most of my clients find that my perspective on their eating helps them to be less critical of their eating. They see that their overeating followed too long a span of time, or that their recurring hunger makes perfect sense, given the large volume of food devoid of adequate calories they were consuming.

Recording allows you to distinguish between physical hunger vs other eating triggers. Recognizing that you weren't hungry helps you to realize that something else contributed to your eating. Seeing that you were hungry but didn't eat, forces you to ask yourself what your intentions of restricting were.

Recording the food you've eaten also takes it out of the closet, so to speak. It legalizes eating. And hearing someone like a Dietitian react not in the way you'd expect—rather, acknowledging how delicious the brownie might have been, or that you only had 3 versus the whole package of cookies, or that you seemed to have needed to eat when you did and it was great that you entitled yourself to do so—get the idea? These messages help to counter the negative assumptions you have about your eating, and may help you feel more justified to eat in a balanced way. No, not the way you think you should be eating—full of restrictions and deprivation, but a more human way of enjoying food.

Would you sleep or do other things on your kitchen table?
(Ok, you don't need to answer that.)

Identifying the location you eat in is also quite important. Do you only eat when driving—where no one can see—not even you? Do you do a lot of eating in your bedroom late at night? Must you eat your food alone, out of the watchful eye of family members?

And what do you choose to eat? Do you limited your selection to diet foods, light in calories and in satisfaction? Do you include a range of nutrients including fats, carbohydrate and protein—or tend to shy away from one or more of these groups? Do you allow yourself to really eat what you like—not just to eat it, but to see it and take it in with all your senses?

Sure, there are some of you that feel so overwhelmed that recording feels like just another chore—which it is. And some of you feel you just can't get organized to remember to write things down. But largely most readers may prefer not to know—not to see it, not to acknowledge what you've eaten—at least on the days you didn't think you ate as you should have—and so you don't record.

If you're serious about shifting your relationship with food, get yourself a notebook you can keep in the kitchen. Or do you live with your smart phone at your side? Check out a fabulous free app, Recovery Record, which leaves off the nutrition details common to so many apps, but appropriately includes the thoughts, feelings and behaviors that so influence your eating, and how you feel about yourself. Then get started. And be sure to share this info with a professional experienced in this area—not the gym trainer who may have a slightly different way of seeing things.

And do start by moving your scale out of site. It is much more challenging to begin to trust yourself when you are being jerked around by that object on your bathroom or bedroom floor constantly.

Thoughts? Comments? I'd love to hear from you.

Thứ Sáu, 20 tháng 7, 2012

Who’s Telling You What to Eat?

RDs? Nutritionists? Trainers? Finding healthy, sensible advice to change your relationship with food.

Don't let me teach you to juggle! And don't let some
clown pretend to be a nutrition expert!

I thought about doing a spinal adjustment on my overweight patient with back pain, but then I realized “Hey, I’m a dietitian, what am I thinking? I have no expertise in this!”

Ok, I’m kidding. I wouldn’t dream of guiding clients in areas I am not qualified (although I have made suggestions about stress reduction I would never consider myself a replacement for a therapist). Educating clients on target heart rate and setting realistic exercise goals based on their current health is one thing, but I wouldn’t instruct them on bench presses. Subtle mistakes and misinformation could lead to major problems.

So why don’t other provider types feel the same way when it comes to doling out nutrition information? Take chiropractors for instance. What extensive training qualifies them to tell you how to eat? Or to sell “toxin cleansing systems”, aka serious laxatives, to bulimic patients (I kid you not), all for the sake of a giant profit? Yes, I really had to coach a patient to return a product to her chiropractor who had convinced her that this was the answer to her woes. Thankfully, I was successful.

Trainers and coaches, perhaps well educated in their field getting people exercising, seem to misinform their clients more than most practitioners, requiring a great deal of my time to correct. They propagate fitness magazines’ and supplement manufacturers’ myths about carbs, and protein (they see a major halo around this nutrient) and base their guidance on their own unhealthy beliefs. Not all providers, of course—but many. They share what they believe has worked for them—which has little to do with what is healthy or appropriate for you! Even the Pilates studio I go to is now selling purgatives in pretty packaging suggestive of clean, fresh and natural health. If only they were aware of the damage of these senna filled disguises. Uggh!

I can at least support the "celebrate recovery"!

Then there are those that proudly call themselves nutritionists, which is actually quite a meaningless term. A nutritionistcould be a steroid-infused guy pushing supplements at the local vitamin store, with no qualifications for this position other that his availability from 9-5. Or it could be the produce manager at the local Whole Foods or other market. Yes, anyone can call himself a nutritionist.

Admittedly, I too, have referred to myself as a nutritionist—a nutrition consultant my business card still reads. Like others, I began to use this term as a way of differentiating myself from the stereotype of food service dietitians of days gone by. It was a way, perhaps of putting a more updated spin on who we are. The difference, though, between me and those other nutritionists is that I also have very valid credentials in my field—RD, MPH, CDE, LDN (see below for definition of these credentials).

Why should you care about the initials?

Credentials are not just for bragging rights. Rather, they help to separate providers based on their qualifications. There are many bright and well-educated nutritionists—faculty members, PhDs often, who are not Registered Dietitians but rather academics with post docs in nutrition. But while they may have a wealth of wisdom about nutrition research and science, they often lack the clinical and likely the behavioral expertise of someone with an RD with years of experience working with patients. As a result, their recommendations may be less than realistic.

That said, credentials are just a starting point. There are many RDs with good qualifications that I would never refer to—they are too inexperienced or rigid in their approach. So if you are looking to work with someone, it’s critical that you learn about their experience, their philosophy and their approach to shifting your relationship with food.

Potential for danger

A sign I came upon in Zermatt, Switzerland

A family member living in another state recently contacted me about the guidance he received from a nutritionist. He was instructed on a Paleo Diet—apparently what this nutritionist puts everyone on, regardless of their symptoms. When his symptoms worsened, she said to switch to gluten free and lactose free. But she also suspects heavy metal toxicity. Or, she added, maybe a parasite. Or something. But in the meanwhile, she prescribed her diet “remedy”, with absolutely no evidence to support it. Oh, and she strongly encouraged a paycheck's worth of supplements which she could conveniently sell him.

And in the meanwhile, this relative is wasting away from his already underweight place. He’s feeling weaker and is nutrient deficient. But he clings to the very personal guidance he’s getting from the nutritionist. MDs have not yet identified his diagnosis nor cure, but this nutritionist is giving him hope. The problem is, this hope comes with a price; namely reducing his energy level and his muscle mass, imposing restrictive (and unnecessary diet rules) and dangling more hope that there is more this quack can do for him.

Perhaps it seems harmless enough. After all, he wasn't getting anywhere with his regular practitioner.

But it absolutely is harmful! Restrictive diets that result in weight loss in those in no position to be losing weight are irresponsible. They may stall constructive, valuable follow up with appropriate specialists. They add confusion to an already overwhelming treatment course. And they provide a false sense of trust—and hope.

Finding the right dietitian

Sometimes, it's hard to know what advice to take!

Philosophies may vary, but I’d suggest avoiding anyone suggesting you eliminate whole categories of foods or nutrients, such as carbs, grains, dairy, etc.
Avoid those whose recommendations are based solely on their personal experience and lack evidence-based recommendations. It’s no better than a LICSW who starts her session using Tarot cards (this, too, I’ve heard about). Fun, maybe, but not a sanctioned, proven therapy!
Learn about their experience treating those struggling with your particular issues. More experience is best, of course.
Do they come recommended from other health care providers or peers you can trust? Do they work in collaboration with your other practitioners? This, too, is critical.
Do they believe you can change? If they view you as unfixable, damaged goods, discard them and move on to another provider, please!

We are bombarded with nutrition information and much of it is conflicting and inconclusive, some of it downright wrong. And the more confused we get, the less likely we are to take action, to make the necessary changes to support our health.

So choose your providers cautiously. Select those that can intelligently sort through the overwhelming overload of food rules you’re hearing. And be on guard for quacks and those simply stepping out of bounds, dispensing information out of their field. Or even worse, selling you useless and often harmful products for their personal gain.

As for my philosophy?

How great is this?!
You can purchase it from their website: http://bit.ly/Mr4gmv

Maybe it’s because I’ve got 26 years of experience behind me. Or perhaps it’s the effect of being diagnosed with a chronic progressive disease (I’ve got Multiple Sclerosis). But personally and professionally I’ve come to believe that life is too short to deny ourselves what we truly enjoy eating. Of course, if you’ve got a severe food allergy (or other such condition) and your survival depends on dietary changes, that’s obviously quite different!
You need to weigh the costs and benefits of dietary and lifestyle changes. Sure, weight loss may be appealing, but at what price? Is it really worth the deprivation, the denial, the decreased energy, and the obsessive thoughts to achieve an unrealistic rate of weight change or even an unhealthy weight?
Food should be enjoyed with all your senses—regardless of your weight. Everyone deserves to nourish himself and to enjoy eating.
Change is challenging, but worth making to improve the quality of your life. And it’s not too late to make it now with the help of a qualified RD.

The credentials:

RD: Registered Dietitian

MPH: Masters in Public Health, in Nutrition (UNC Chapel Hill)

CDE: Certified Diabetes Educator

LDN: Licensed in the state of MA

Not listed: BA in Biology, Brown University, Providence RI.