When fat things happen to good people. On being thin, fat, and your false assumptions.

"Such crazy thoughts in that Aussie article!"

Do you think that if only you do the right thing—eat a healthy diet, exercise, get enough sleep—then you will achieve your dreamed of weight, live free of disease and live happily ever after? This, dear readers, is a fairy tale. 

If you believe that eating nutrient packed, low calorie foods is solely responsible for whether or not you get cancer, or arthritis or MS, think again. And don’t be fooled by the preaching of Dr. Fuhrman in his book, Eat for Health, that health equals nutrition divided by calories, period. Health is not such a simple equation. And no, eating whole grain, veggie packed meals won’t protect you from an eating disorder either. 

If you think that eating 'right' ensures thinness, as was recently emphatically suggested in a popular newspaper article in Australia, it is yet another fantasy.

And if you torture your overweight self with the belief that you must lose weight--at all costs, and that your inability to reach target goals based on BMI charts is your personal failure, you’re wrong again.

“What is she thinking?” you’re thinking? Let’s start from the top. 

Eating healthy equals health

Yes, diet can impact many, many health measures. And I certainly encourage a balanced, varied diet filled with a complement of vitamins, minerals, antioxidants, and an appropriate level of fiber, to name a few. Yes, there are correlations in populations that have higher intakes of alcohol and saturated fat, for instance, with increased rates of cancer and high cholesterol, respectively. And a nutrient-rich diet chock full of antioxidants and lycopenes, like those found in tomato-based products, may help stave off such conditions as Alzheimer’s, cancer, and other diseases. But eating a proscribed diet will not guarantee your health. Nor will it ensure happiness, which is not to say I don’t encourage making healthy choices—I surely do. But do not, for a moment, think that if you are fortunate enough to stay healthy (or unfortunate enough to become ill) that it is solely by your hand. Credit your parents for their genes, to start.

Fallacies about thin

And do you know what? Eating well does not ensure thinness either. I see my share of patients who choose the most wholesome foods, but eat in excess—even those nutrient rich, heart healthy foods, like avocado and almonds, lean protein and kale. By excess I mean frequently eating without regard for hunger, and eating past a point of comfortable fullness. And eating well—high quality, nutrient-rich foods—even eaten mindfully and intuitively—may not keep you slim. Yup, it’s a sad truth that many of you don’t want to hear. And in fact, the very act of pushing your body to be a weight it is not meant to be, may put you in worse shape—both physically and psychologically. Just wait until you hear about these studies!

Stay tuned. That’s my next post, based on fascinating research presented at the Renfrew Conference I attended last weekend.

And those who are thin do not necessarily eat well and are often hardly fit by any standard. Do be careful about equating weight with health because they do not always pair up as you’d expect. Individuals may be thin because they are genetically predisposed to be, or they may be thin because, in contrast to what journalist and dietitian Susie Burrell believes—that they “know what to do to control their weight”—they may fall quite short in controlling it appropriately. They may be no better than someone who binge eats for emotional reasons at knowing “how to cope when things are tough”. Don’t be fooled into assuming that thinness is simply a lifestyle choice, a moral higher ground.

And I’d caution her, and you, not to overgeneralize about thin people’s skill at “assuming responsibility for self”. Just spend a few hours in my office; even those without eating disorders may allow anxiety or depression to stand in their way of eating enough. How responsible for self is the person who denies herself nourishment when low energy or headachy—hunger gone too far—or pushes herself to exercise even when she reports constant fatigue, or pain? 

Eat when they are hungry, stop when they are full? Some thin people may. But overgeneralizing about a segment of the population isn’t too intelligent. 

No, I didn't leave the rest over, for the record.

Thin people may self-regulate just fine. Or they may deny their hunger and fluid load or rely on high volume low calorie foods. They may eat nourishing foods, or a diet of junk—just not excessive in calories. Or they may compulsively exercise, hardly resulting in mental health, potentially leading to loss in muscle mass, heart problems and a range of symptoms if accompanied by undernourishment. Really, the only thing you can generalize about thin people is… that they are THIN. You can’t assume they are healthy, or happy, or good at self-care or self-regulation.

And of course the reverse is also true. The only thing you can tell by looking at a fat person is….? Yup. It’s that they are fat. You cannot predict their lipid levels or their blood pressure. You can’t tell whether they’ve never exercised or they exercise too much. And you can’t determine the quality of their diet.

My own parents are perfect examples of this, as I’ve written about previously. 

The mere suggestion that health is 100% in our hands I take offense to, as would the rest of the population which struggles with MS, and cancer, and ALS, and type 1 diabetes and arthritis and, and and… And I can say the same thing about a target weight or size. I hate to break it to you, but even if you do all the ‘right things’, you may not achieve your desirable, fantasized-about weight. And you know what? It’s not your fault.

Stay tuned for part two, (which I hope to get out within the week), which will address obesity, weight loss, and the risks and benefits of change.

Did this post push your buttons? Did it challenge your thinking? Did it offer some relief? Do let me know what you’re thinking! 

Thanks for reading, and if you liked this post, please share!

Fat enough. Coming to terms with weight when it’s less than ideal.

I don’t know which made me saddest—her sense of vindication when reporting the oncologist’s orders: “I don’t want to see any more weight loss”, or her distress that her weight was up 5 pounds. Or perhaps it was her pride in getting down to the lowest adult weight she has seen in many decades. Ahh, the perks of esophageal cancer!

She’s lived so tormented by her weight, berated by doctors and non-supportive family members to reach for something unattainable, to get thin, from the time she was a pretty, young, school-age girl. “You’re beautiful”, they’d say, “if only you could lose some weight.” Perfect labs and low normal blood pressure were not good enough. No, she didn’t look fat on paper.

And yet her obesity just might have been the source of her potentially fatal illness. There. I’ve said it. Admittedly, GERD, gastroesophageal reflux, is linked with manyfactors, and obesity is just one of them.  But after a decade living on antacids, popping Rolaids like LifeSavers—no pun intended—with a blood sugar approaching diabetic levels, she had gastric bypass. The GERD? Finished! Antacids were no longer a fixture like Kleenex and lipstick in her purse. Yes, she was free of heartburn and indigestion—and her blood sugars dropped to normal. With her 90 pound weight loss came a reversal in symptoms and the promise of a better life.

So it came as a quite a shock last year to learn that she had esophageal cancer. And hers, located at the very bottom of the esophagus near the stomach, was not a result of alcohol or smoking but from many years of damage from acid reflux.

GERD can lead to changes in the cells of the esophagus—between 5 and 10 % with GERD get Barrett’s.  And Barrett’s Esophagus can develop into cancer, with an overall lifetime risk of 5%. 

Could it have been prevented in her case?

Sure, earlier screening by endoscopy to evaluate progression to Barrett’s sooner could’ve helped. And being more proactive with a procedure called ablation to wipe out the changed “Barrett’s” cells would have helped too. 

As for weight loss?

It’s not that she didn’t try. Perhaps she was genetically meant to be a large woman with a high BMI. Still, she could have worked in more activity, walks at least, something, setting realistic, achievable goals. And stress reduction to prevent emotional overeating and anxiety-driven overeating.

Yes, those might have helped her weight and subsequent chronic reflux and possibly prevented her cancer. But in our society it would never have been enough. She would still be viewed as obese, with the stigma we project on that label. Doctors would still say her weight was too high, falsely envisioning the fast food drive-ins she never frequents. (Actually, her meals have been quite healthy and balanced for as long as I could remember.)

In spite of her post cancer, post surgical weight loss of more than 40 or 50 pounds—honestly I don’t know how much exactly—following the doctor’s orders and not striving to lose more weight is quite a challenge. Self-acceptance doesn’t suddenly appear at age 75 when it has been long absent.

So please don’t wait until changing is a matter of life and death. Seek support for working on self-acceptance. And try to see your weight as just a number—not a reflection on your character, nor your motivation, nor your fitness level or your health.

Thanks for reading.

And yes, I've written about this before with a bit of a different focus.

Not thin enough? Not sick enough? YOU—eating disordered?

I’ve done it. In just a few sessions I made my mark on a future generation of nutrition providers—an intern interested in eating disorder treatment, no less. She was, like most, biased by the sensationalized images and the media’s descriptions of emaciated anorexics; of teenage girls who ‘just wanted to be thin’; and of visibly unhealthy looking bulimics. Those were people with eating disorders, she believed.

Yet in the few days she has spent with me, she’s seen anorexic men, normal weight binge eaters, and women in their 40s, 50s and 60s struggling with eating disorders. Some developed their disorder recently, some only recently presented for treatment, having struggled with their relationship with food for decades. All are pained by their condition—no one chose to live with a disorder. Really, there are places they’d much rather be than in a medical office on a nice summer day.

Yet what they all have in common is that their appearance is not a give away. Most look just fine, I must say. (Although I’ll admit that without their layers of clothes some would be viewed as significantly underweight.)

Yet most carry their disorder on the inside.

It’s unfortunate, really, because as a result, they have suffered silently. Their doctors and health care providers never knew to direct them for the necessary expertise and failed to support recovery. And often they put their foot-in-their-mouths with inappropriate comments about weight or “healthy, runners’ blood pressures.” If only they could have seen it. If only it was as clear as the media portrays it. If only they knew that most people living with eating disorders don’t look like they have an eating disorder.

If you didn’t know to ask, you’d have no idea that perhaps 95% of their thoughts are spent perseverating about when they will eat next, and just how much; about whether their stomach is still flat, or whether they will have access to a bathroom after eating to purge; or whether they’ll have an opportunity to binge without anyone to witness it. If only medical providers thought to evaluate food intake and behaviors before the comprehensive, costly GI workups which fail to identify the cause of the chronic distress from hunger or slowed motility, or the reason behind the heartburn—namely, the chronic purging.

How helpful it would be for primary physicians or the referred-to neurologist seeking an answer to the puzzling chronic headaches. No, no one considers inquiring about the time between eating and the food restriction. Yes, migraines and other headaches occur more often with under eating.

Hope comes with new DSM

Fortunately, the new DSM-5 guidelines may help. They’ve changed the criteria for defining anorexia, removing some of the requirements that kept individuals from getting the help they needed. And, from misleading health providers about what eating disorders really look like. Now, rather than defining anorexia by using a specific weight change (such as the previous 85% of normal weight) it appropriately offers a broader definition. A low BMI is not a requirement for diagnosis!

The guideline states “the clinician should consider available numerical guidelines, as well as the individual's body build, weight history, and any physiological disturbances". In other words, an individual who is objectively overweight or high BMI can now, fortunately, be fairly labeled as anorexic if he/she has restricted intake resulting in significant weight loss together with physiological signs of starvation together with meeting all other criteria for the diagnosis. And, missing a period is no longer a requirement for diagnosing anorexia. That certainly may impact the many men out there struggling with feeling like an imposter with a ‘women’s disorder’!

No, you don’t have to fear that your weight isn’t low enough for your disorder to be acknowledged. And you don’t have to look like an adolescent poster child for anorexia.

No longer should you feel you need to lose weight to fit the anorexia definition to enable treatment or, for that matter, to validate your suffering. No longer does EDNOS—that vague ‘not otherwise specified’ diagnosis—need to be used for those restricting, nor for those suffering with Binge Eating Disorder (BED). Yes, you aresick enough.

Anorexics are 60 lbs. And individuals with anorexia are also 200 lbs. Dropping weight with severe food restriction is no less serious if your 30 lb. or 50 lb. weight loss brought you to 130 lbs. or to 90 lbs. Thank you, Deb Burgard, PhD, an AED member and blogger for HAES, for making this point loud and clear.

Having a BMI in the healthyrange is hardly healthy if you are compulsively exercising, purging or restricting to maintain this place.

I’m so glad the intern gets it. It will make her a better provider when the time comes to practice, as she will now know to ask the questions to help identify and ultimately support recovery from an eating disorder.

But have I made my point strongly enough for you to hear? Please pass this along to increase awareness—to your friends and family members who you’d never know might be suffering—and to your medical providers who never thought to ask.

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:

1. Eat enough calories throughout the day. Guidance from an RD can be quite helpful here.
2. 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!
3. 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.
4. 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…
5. 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:

• http://www.dropitandeat.blogspot.com/2013/04/intuitive-eating-is-not-for-youmaybe.html
• http://www.dropitandeat.blogspot.com/2012/11/you-can-pull-it-off-but-it-wont-be-pain.html
• http://www.dropitandeat.blogspot.com/2012/10/whats-point-ive-already-blown-it.html
• http://www.dropitandeat.blogspot.com/2012/09/what-ive-learned-about-food-addiction.html
• http://www.dropitandeat.blogspot.com/2012/10/trying-to-change-your-relationship-with.html
• http://dropitandeat.blogspot.com/2010/11/honor-thy-hunger-and-thy-fullness.html
• http://dropitandeat.blogspot.com/2010/11/morning-after.html
• http://www.dropitandeat.blogspot.com/2012/04/0-false-18-pt-18-pt-0-0-false-false.html
• http://dropitandeat.blogspot.com/2010/12/minding-your-eating-managing-your.html

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.

Weighing In: Can't Bear to See it or Can't Tolerate Not Knowing?

You might imaging all kinds of things are happening
to your body if you don't have the facts.

It's time to hear from you. That is, if you have an opinion on knowing your weight. Does anyone not have strong feelings on this topic? I'm prompted to write this post having recently debated the merits of having clients see/not see their weights. And among us eating disorder professionals, opinions are pretty strong about what's the best approach. And we don't all agree.

On the one hand, whether you're dealing with anorexia, bulimia, or binge eating disorder, seeing your weight early in treatment can be a disaster. It can distract you from trusting the benefits of eating better, of listening to your body, and of nourishing yourself, shifting the focus simply to the number and all you associate with it. It can derail you from staying the course and normalizing your eating--because your preoccupation with the number stops you in your tracks. Often I address the relative change in weight--whether it increased, decreased, or stabilized, is in range, is 'where it needs to be', is 'as expected'--whatever language we've decided would be tolerated, patient by patient.

That of course can lead to use of your very creative imagination! If I say 'things are going well, we don't need to make a change this week' you might jump to conclusions and imagine that you've gained ten pounds or so. Or you might assume that since you've gained--while eating less than you were supposed to--that you'd better cut back this week. Or it might provide reassurance that your worst fears didn't come true, that all is safe--as long as you trust my feedback.

Some providers approach it completely differently. They tell patients their weight, and then they spend time debriefing about it in a very therapeutic way. It removes the 'what if's', because you know exactly what happened. But it can also cause panic and halt your progress; it may make it challenging to continue to stay on course with your eating.

Ultimately, as providers I believe we need to assess where each individual is at. Are you at a place where you can take in information about your weight? Are you able to look at weight change in perspective, or will it cause a set back?

What's your thoughts on knowing your weight as you change your relationship with food? What would you recommend to your provider about weighing and giving you feedback about your weight?

Thanks for taking the time to comment.

Which One Really Needs Help? Call the Doctor!

Even Mica was disturbed by this!

I know, I know—I’ve got another 5 days before my expected post is due, but I just can’t wait. I can’t let Laura’s painful experience go unaddressed. If you haven’t read it, please do so now. But brace yourself—you’re gonna get angry.

It’s not unusual for me to hear and read about inappropriate statements and suggestions that medical providers make. Actually, we all can manage to say stupid things—I know I’m no exception.  (Really, no need for those that know me personally to comment on this statement!) But today I heard two doozies—Laura’s tale and a patient’s story.

I don’t know Laura—except, that is, from her blog comments. What I do know about her is that she has made extraordinary progress in her recovery from anorexia. That she can now enjoy pizza! That she gets it—and she follows through with healthy, normal, eating behaviors. That’s she’s worked hard to put all the disordered thoughts aside and use her wise mind to justify doing the right thing. That she, like many others, have needed to use self-talk to move from the myths, the misinformation, about nutrients and foods and weight. Ahh, she’s done so well. I don’t even know her, but I am so proud of the work she’s done, of how far she’s come!

And then someone she respects, her MD, albeit inexperienced with eating disorder, totally sideswipes her. The respectable doctor projects, I suspect, her own mishugaas—about weight control, about carbs, about fats. Our wise Laura knows better—but of course when the white coat-clad MD begins her critique of Laura’s intake it’s simply devastating.

Yes, you can eat the whole panini if you're hungry!

What I read in this comment is not that it triggered her eating disorder; she concludes by stating that this doctor just didn’t work out. (Hooray for Laura! Time to change doctors—or get her to close her mouth and withhold absurd and inaccurate assessments of Laura’s intake!) 

But, I suspect, it’s the profound sense of disappointment in her doctor, and perhaps in our crazy food-and-weight obsessed society, as a whole. Laura appropriately acknowledges that there are absolutely no grounds for this doctor’s comments—she has zero evidence to conclude that Laura is struggling with her weight, or unhappy with her intake or struggling with eating disorder behaviors. 

Perhaps if she had asked more open ended questions—you know, like “How’ve you been feeling about your eating these past weeks?” or “What concerns would you like to address about your recovery?”, she could have prevented this damage. It would make a lot more sense than projecting that there’s a problem, simply because Dr. Dieter has perhaps struggled with her own weight and her eating!

Hats off to you, Laura, for having the sense to air your feelings and get support—and for sharing your reaction with the doctor. Hopefully, she’ll learn from her mistakes. And hopefully, you’ll find an MD that really gets it!

As for the patient story? Nothing too unusual that you haven’t heard before. It’s a case of an MD who looks at a 20-ish patient and tells her that her weight should be about 50 pounds less than it is—which would bring her to a place she has never seen on her growth curve. It would bring her BMI to a percentile lower than ever before, even since grade school! Fortunately, this young woman appeared to have a good sense of self, knowing darn well that this MD’s goal was crazy.

If she is appropriately nourished and growing
along her curve, must we make her weight
an issue?

But what if she took the doctor’s orders to heart and began to fight her body on what was normal? To push activity to an obsessive level and to restrict her intake to a point that was neither healthy nor maintainable? What if she had the genetic predisposition for an eating disorder and all it took was the encouragement of a doctor to set the ball rolling—given her own frustration with her recent weight increase and being told her BMI was in the obese category? This woman was more fit than most people I know and had no health issues. She ate healthily and exercised. And there likely was an underlying medical explanation for her recent unexplained weight gain, yet to be determined.

See the problem? Do they even realize the power of their words?

Do you even realize the power of yours? If you are on the receiving end of poor advice, do share your concerns. Consider another opinion from someone you trust. Or do like Laura did—contact the MD and respond. And if you need to, move on—and reach out for support.

Feel free to share your own horror stories, or simply to express your opinions.

Thanks for reading.

Advice for Your Doctor for NEDAW

Call me crazy, but I’m tempted to respond to a doctor’s closed-ended questions in ways that would knock his socks off. When he asks me about alcohol, for instance, he frames it something like this “you don’t drink much, right?” Or perhaps to assess risk of STDs he suggests “just one partner—you’re married, right?” Well, yes, he’s right, but would I ever say anything other than what he’s led me to believe is the only acceptable answer possible?

Isn't it time to get the support you need?

This brings me to the important topic of educating your healthcare team, your doctor, in particular, about how to truly support you. In honor of National Eating Disorder Awareness Week (NEDAW) (here in the States) I thought that health care providers could use a bit of awareness, to hopefully make your visits, and your life, a bit less stressful. Please consider adding your own two cents to the comments—then pass it on to others—and your providers! While this is prompted by NEDAW, I’ve included recommendations that are worth sharing regardless of whether you struggle with an eating disorder, disordered eating, or simply are outside of what the BMI chart says you should be.

Unsolicited Advice From One Healthcare Provider To Another

On weighing your patient

Please weigh patients with their back to the scale. Have them remove all layers possible—most individuals, regardless of their weight, want the weight to reflect what’s real. Weighing with shoes, heavy belts, and jackets doesn’t contribute much valid information. Oh, and have them empty their pockets!

That said, some do want to misrepresent their weight—so less is always better—with regards to clothing. And have them empty their bladder first!

A poker face and restraint from commenting is wise. That is until you’ve gotten to assess their weight in context. Imagine if you said to an overweight patient—“great, you’ve dropped a ton of weight” only to realize that they had a rapidly growing cancer? 

Weight change must be evaluated relative to behavior. Someone who lost weight (regardless of how appropriate you thought it was for them to drop some pounds) may very well have gone about it the wrong way. 

Consider this—they may have been starving themselves, resulting in messing up their periods, their metabolic rate, their mood, their sleep, their thoughts, their relationships.  This is nothing to offer positive reinforcement for. There is nothing healthy about losing weight this way. Perhaps they are compulsively exercising, or dehydrated from purging or laxative abuse. No, weight would not be a good measure of health then.

Similarly, your patient with a high BMI might have simply maintained her weight. But she feels well, is active and fit, and is healthy by all measures. Maybe she has even turned things around, if her weight had previously been climbing. Sure, you can explore other risk factors, such as quality of her diet—as I hope you would do with your slim patients, too. But if all looks good, perhaps you can accept that her stable weight is just fine for her.

Perhaps if she’s been climbing in weight that might warrant some probing about recent lifestyle changes—stressors, activity, diet—to help with better self care and disease prevention.

And if your underweight anorexic patient has increased his weight, please similarly temper your response! While you may be delighted, he (or she) may not be. It’s a mixed bag, gaining weight, even for those who are trying to gain weight. There’s the healthy side of them that really wants to recover. And then there’s the eating disorder voice that sees weight gain as a failure, as a “you can’t do anything right”, pulling them back to restricting again. It’s more valuable to elicit a sense of what they are thinking and feeling about the change. How does it fit with what they expected? What are the benefits of the changes they’re making? Focusing on the behaviors that contributed to the weight shift is more valuable than discussing the weight itself.

If your patient isn’t doing well, rest assured that they are as frustrated—even more so, really—than you are. The impact is far greater on them than on you, that’s for certain.

Hooray! You got your period back!

It’s not healthy to lose one’s period due to such factors as anorexia, restrictive eating, or compulsive exercising. We all know that. But while getting a period back is a good sign, it is not always well-received by patients. For some, getting a period equals “I must be fat now”. For others, it means they are done with their efforts to change their eating and behaviors. And that may be the worse thing for them to conclude.

Periods may return before weight is restored and before behaviors are normalized. Or they may come back after 4-6 months after stabilizing in a healthy range. Or they may never have disappeared, as was the case of a patient of mine who conceived 5 children through her years living with anorexia. The point? Consider where your patient is at before you rejoice in their body’s normalizing their periods!

Don’t Ask, Don’t Tell? I Don’t Think So.

If you don’t ask the right questions, you won’t get the real answers. So do ask open- ended questions—different than what my MD thought to ask—to obtain valuable information. If you’re discussing weight or body dissatisfaction, do ask if they’ve used laxatives, or diet pills, or vomiting or restricting—in the past, or currently. Suggest a frequency, in a non-judgmental way. If a patient says she purges daily, follow with a question like “how many times per day?” And when he says twice, follow with “And what’s the maximum?”  Just like if they say they have a couple of drinks, follow with what’s a couple—4? 5? 2? Per day? Per week? Suggest a range of possibilities, without raising an eyebrow.

 

We can only help our patients if we can accurately assess their situation. And, we can’t begin to do so if they feel they can’t trust us. So do your part. Ask your questions in open-ended ways, and be careful how you react. Ask how you can help, what they need from you. Are they connected with appropriate resources, or do they need guidance?

Encourage a follow-up sometime soon! 

Suggesting a 3 or 6-month follow-up visit certainly sends the message that their situation simply isn’t worth your taking too seriously. And as a result, they will undoubtedly convince themselves that really everything is fine, that nothing really needs to change.

And if you don’t believe me, read the comments from those in the know, below.

Thanks for taking the time to read this.