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.

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.

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.

Allured By Diet Pills & Laxatives?

I got carded yesterday in the middle of the afternoon. Yes, in spite of my grey hair and my approaching 50^th birthday, I was forced to show my ID. This was not to buy a Chardonnay or a 6-pack, but rather to purchase something taken in much smaller doses—cough medicine. In spite of my visible maturity, the drug store required me to prove I am of legal age for such a purchase, given risks of using these products to produce methamphetamine.

Fair enough. But here's what struck me. At this same pharmacy, just 2 weeks ago, they were giving out samples of Senna laxatives, those natural-yet-lethal stimulants, which are anything but safe, especially if taken beyond the very limited time frame recommended. Use beyond the limited 7 days can result in dependency and can impact potassium balance with major consequences to your heart and other muscles. It’s not recommended in pregnancy or for nursing woman at all, nor for kids. And they certainly aren’t helpful for weight loss, yet that hasn’t stopped people from taking them with the hope that maybe these will get the pounds off.

As you might have guessed, I simply couldn’t keep my mouth shut about their promotion of this freebie back then. And here I am, getting carded to buy a bottle of Robitussin CF to legitimately control a hacking cough.

As I strolled around the store yesterday, I walked through the supplement aisle—just looking of course—lined with supposed diet products to melt the fat away and control weight. Laxatives, Sensa and other diet pills, formulas promising aid for the aging body—those were all there—with no ID required to protect our safety or our sanity.

Why aren't we in an uproar about this scam, about our being manipulated by the promise of this unrealistic dream of harmless weight loss? Why aren’t we protesting the ease of availability, alluring us to potentially damaging products that are deemed innocent enough to stock the shelves—deemed innocent until proven guilty? Why aren’t we shouting about the unwanted and unsolicited junk emails falsely promising weight loss we’re being bombarded with this time of year?

Why, instead, are we up in arms attacking soft drink manufacturers for selling Cola, Sprite and the others fearing their impact on the obesity epidemic?? They promise nothing—at least they're honest! Sure, excessive intake of regular Coke and Pepsi may contribute to obesity and may take the place of nutrients we could be eating. And excessive intake of Diet beverages, in my view, is no less concerning, as it displaces nourishment we all need and provides a false sense of fullness—which those of you struggling with anorexia clearly don’t need.

Buyer beware, is the advice I’ll leave you with. And do consider speaking up if you’re a recipient of unwanted diet promotions!

Desperate for Overeaters Anonymous?

6 Reasons to Skip This 12-Step

It's January and if you watch TV, read Women's (or Men's) magazines, or overhear locker-room talk you know what that means.  Just last week my husband emerged from the gym, biting his tongue having heard a couple of guys talking about white flour and 'bad' foods to eat and their New Year's resolutions to strike them from their diet.

Yes, one of us bites his tongue. I, on the other hand, feel compelled to discuss the issue further.

Why a post on OA anyway, you ask?

Because I have been hearing tales of OA meetings, about Grey Sheet, about control and powerlessness for years now, from clients who’d been involved with OA and wrestled to break out of it’s grip, and from those struggling to move on. And, because I want to point out--as I did in the Weight Watcher's post—what you need to be cautious of if you are considering taking advantage of this program.

But first, here’s a disclaimer; I have never personally experienced Overeaters Anonymous meetings, nor the sponsor relationship, although I have read through their booklet several times to ensure I am taking their information first hand as well as through the filter of its ex-members. I am writing based on what I frequently hear in my office, from those who have left the group, often with mixed emotions. They left, ultimately because they realized it wasn't working for them, sometimes feeling a longing for the camaraderie of the group, sometimes seeing their departure as their own failure. But often recognizing that the OA approach was ultimately far from healthy.

Overeaters Anonymous is a peer led support group based on the 12-step model of recovery. What's 12-step, you ask? Here's a link for an explanation:

http://en.wikipedia.org/wiki/Twelve-step_program

Twelve-step programs are fabulous for helping individuals take control when struggling with a range of addictions—such as alcohol and drugs. But eating should not be so black and white, with columns of drug-like foods and good food. We can compulsively overeat on anything—given the right setting and triggers.

So what's my beef about this 12-step program for compulsive overeating?

1. It's free. But you get the expertise you pay for.

Guidance and support abound, by well-intentioned individuals (called sponsors) struggling with their own compulsive overeating. And their approach to managing food is simply avoidance. Are sweets an issue? Ban them. Bread? Ban it. Anything white, as in white potatoes and white rice—purge them from your diet. Admittedly not all OA members follow this rigid approach (aka Grey Sheet), which has supposedly lost favor with the organization. Yet even in their descriptive program booklet, there’s specific reference to avoidance of these foods.

It appears to me, from my patients’ descriptions, that issues of control around food get transferred to control in the sponsor-member relationship. Instructions and repeated check-ins and accountability come from sponsors, lay people struggling with compulsive overeating themselves. They are not trained professionals, and draw only from their specific issues and experiences. Patients have described feeling shame and the need to be dishonest with their sponsor, and they ultimately complain of difficulty being released from the hold of the sponsor even after deciding to leave OA.

2. You decide what you eat?

With Overeaters Anonymous, you can follow whatever diet you please—it's up to you, not them! “We choose what’s appropriate and nutritionally sound for ourselves”, they say. Sounds perfect, no? Yet this can be dangerous, if you are misinformed as were the gym goers my husband overheard or if your thinking is distorted from years of diet rules. If you believe that limiting your intake to fruits and vegetables is adequate for yourself, I just wouldn’t agree. There is a place for some reality checking with a professional!

3. We must admit we are powerless over food?

That's their ‘step one’ so it’s no surprise that OA and I differ philosophically here! No, I do notbelieve you are powerless—although you may certainly feel powerless around food. Yes, when you have under eaten throughout the day, you will feel out of control when food finally appears. When you are stressed and have not yet learned alternative means to manage your feelings other than relying on food, you will overeat. And if you feel you are not entitled to eat—because you shouldn'tfeel hungry, or if you desire something palatable but feel that you are not entitled to eat what you enjoy simply because of your weight—surely you will eat it compulsively and feel powerless. “Our mind/body as compulsive eaters is different than a normal eater…” they say, and I couldn’t disagree more.

4. “Spiritual growth is the basis for stopping and maintaining compulsive free eating.”

That’s what they say in their manual. Sure, a sense of peace and inner calmness will help you move away from compulsive eating. But frankly, if someone leaves a plate of home-baked brownies on your kitchen counter, even if you’ve had a spiritual awakening, you’ll likely still eat more of those delectable baked goods than you intended—and there’s nothing disordered about it! Rather, it’s a pretty normal response, triggered by our senses. And if we’re distracted at the same time, we’ll likely eat more. And if we’re hungry at that time, we may consume them faster and in greater portions. I’m all for spiritual growth, but you don’t need to believe in a higher being to take control of your eating.

5. “Then we need a plan of eating…that includes refraining from particular foods and or specific compulsive behaviors.”

Unfortunately, restricting food intake and creating lists of good vs. bad foods does nothing to change your long-term relationship with food. Short term, this black and white view may seem to serve you well. But after some time, thoughts about the forbidden foods, longing for what you miss eating, and ultimately overeating on that which you’ve eliminated, will result. But you may just blame yourself instead of this outrageous approach that itself contributes to your lack of control around food. I do not endorse their approach of identifying and then eliminating all foods that you struggle to eat in control.

“Think of it not as deprivation but of as a positive act and spiritual discipline…” they urge. Really? Is this the kind of guidance that will help free you from disordered thoughts around food and eating? I don’t think so!

6. Where do we agree?

I support OA’s interest in helping you move away from unhealthy behaviors, including [my additions in parenthesis]:

• Eating until (uncomfortably) stuffed
• Rigidly restricting (your food intake and the foods that give you pleasure)
• Having to clean your plate
• Hiding, and hoarding food
• Distracted eating
• Purging and restrictive dieting

“These behaviors should be stopped.” They say. And with this, I agree. But their recommendation to follow a 3-0-1 plan to include only 3 meals with nothing in between is simply absurd. It will neither stop your behaviors nor your preoccupation with food and eating.

So now where can I turn?

Support groups can be quite valuable, but I’d advise joining one moderated by a professional in the eating disorder community. In Massachusetts, check out medainc.org, or explore your local eating disorder organization. Yes, compulsive overeating is an eating disorder and needs to be address by professionals whose treatment is based not on their personal experience, but on years of clinical expertise and guidance from evidence-based research. Well-intentioned free guidance can cause more harm than good, as you‘ll struggle to let go of the additional set of rules they’ve imposed.

For more on this topic, check out What I've Learned About Food Addiction, Black and White-Great for an Outfit, Not for an Outlook