My Mother’s Day Advice.

From the MFA, Boston, MA

I’m not your mother. But the mother in me wants to share some motherly thoughts. Won’t you indulge me in this on my annual holiday? 

Yes, I yearn to do motherly things like feed you—knowing full well that moving past your eating issues and your eating disorders takes way more than my cooking. I fantasize that I can have you all over for a meal and you can eat it and enjoy it without compensation, without unhealthy thoughts and behaviors. That you can see how safe it is to eat. If only it were this simple.

So instead I’m sharing some nurturing guidance, whether you are 20-something or in your 50s.

Indulging at a favorite cafe with my
mom and my son.

Words from your non-mother (when not acting as the Tiger Mom)

• Give yourself permission.
• Be forgiving.
• Treat your body as you would expect your child or your sister should treat herself. Respect its limits—don’t exercise when your body isn’t up for it. And please fuel it.
• Be realistic. Setting the bar too high with unrealistic expectations is a recipe for disaster. You will never be able to healthily sustain such changes.
• Slip. Then pick yourself up.  Yes, it’s unrealistic to believe that slips don’t happen, that they shouldn’t happen, that you should know and do better. So move on. The real test of a slip is your ability to stand back up and move forward. Real progress is having fewer slips that are less severe. Real progress is being able to learn from your slips and work on prevention for next time—without beating yourself up.

• Find a Mom. No, it doesn’t have to be your mom (don’t forget—I said be realistic!) Rather, explore your resources, your supports, and ask for help. Yes, you can do it.

Are you my mother?

• Hope, even if you don’t yet believe, that recovery is possible. Because this old Mom knowsthat it is.
• Trust that things can and will get better. Gotta love Ingrid Michaelson’s song Gonna Be OK for the inspiration.
• Appreciate what you do have—what’s in place in your life, as well as with your eating. Check out Noa’s Homemade Religion which truly moves me to appreciate.

Enjoy, dear readers! And please let me know you're reading!

What Your Healthcare Team Needs to Know About Your Non Compliance.

Compliant |kəmˈplīənt|

Adjective

1. inclined to agree with others or obey rules, esp. to an excessive degree; acquiescent : good-humored, eagerly compliant girls. See note at obedient. (From the New Oxford American Dictionary)

A picture of NON-Compliance. Only a biscuit will
motivate him for action.

It’s rare that I have the opportunity to chat with a medical student, a soon to be doctor. But this past weekend I was fortunate. Mike, a bright, articulate, and lovely guy of 28, is nearing the end of his fourth year of his medical education, currently doing his internal medicine rotation. He attends a top medical school in New York City. And you know me. I just had to ask him, this soon to be practicing doctor, a few pressing questions, while strolling along the brownstone lined streets of NYC. Here’s how it went.

LL: “So how much nutrition education do you get throughout your training?”

Mike: “About 5 hours total, in my four years.”

LL: “And what kinds of nutrition topics do you cover?”

Mike: “The greatest focus is on all the vitamins and minerals and their deficiencies—scurvy, beriberi, Wernicke-Korsakoff, to name a few.”

LL: “Wow, so the bulk of your nutrition education is spent studying conditions that we rarely see in our country.” (scurvy is a vitamin C deficiency, beriberi a thiamin deficiency rather uncommon in these parts), with the exception of Wernicke’s which we do see in severe alcoholics (also from a thiamin deficiency).

Further along in our conversation Mike shared his frustrations regarding nutrition-related illness:

“Patients tend to be non-compliant. You know, they don’t do what we tell them, what they need to do to help themselves.”

What does your doctor need to hear from you in
this limited time?

And with that comment, I had to hold back my biting tongue. (He really was a lovely fella, and a friend of my son, so I took a breath and went for the patient response.) Yes, it is frustrating to feel that people could help themselves if only they would follow what you tell them to do, if they would just do it. We discussed the fact that the average length of a typical doctor’s visit is maybe 17 minutes, start to finish; during the length of three songs on your iPod, your doctor needs to assess your medical situation, answer your questions, figure out how best to convey information to you about your condition, educate you and direct you to resources. Sounds easy, no?

Clearly something gets missed in these limited length visits. How can providers expect patients to change when they haven’t even probed to see what obstacles are keeping them stuck?

For better “compliance”, doctors need to better assess patients’ readiness for change. And then provide them with correct information and useful resources to go forward.

Laziness Keeping Her From Exercise?

Maybe there's another reason she (he?) stays where he's at?
And no, I didn't pose them when I too this picture.

You can’t tell someone, like my patient Ellen, who might benefit medically from an increase in physical activity for her blood sugar, cholesterol and blood pressure management, as well as her escalating weight, that she needs to exercise four days per week, 30-40 minutes. Why? Because she associates an increase in heart rate with anxiety, and fears it’ll result in a heart attack. Instead, I had to work on getting her to see that exercise is safe, first and foremost. So I discussed with her doctor getting a stress test done, followed by a doctor’s approval for exercise, to allay her fears. After that, she was able to slowly increase her activity. Now she exercises regularly.

Time To Change The Strategy

 Stubborn and non-compiant--
but who knows what's going on inside his head?

More than one woman I have worked with has shared that her husband has made it clear in no uncertain terms that she shouldn’t be eating what she eats, or weighing the weight she weighs. The result? An “I’ll show you” response—she eats beyond her need, when he’s not around, in part to spite him. Acting like her husband, telling her what to do, judging her by her size, will ensure that her weight continues to climb. Instead, directing such patients to work with a therapist to better communicate with their spouse (and others) and speak up for them selves can help. And enlist their suggestions, their ideas for practical change. That’s a way for providers to successfully problem solve.

And such patients need to be given permission, with practical strategies, to bring food out of the closet. I often recommend that they tell their spouse what to expect—that they will see them eating foods the spouse deems unacceptable for weight management—and they shouldn’t be surprised. And their spouse should withhold comment and judgment, thank you very much. Only then can we expect “compliance”.

Information Can Cause Slips

Health care providers need to check their facts, before being quick to disseminate information. Telling patients “cut out your carbs” is simplistic and unnecessary, including for diabetics. And you can bet it’ll lead to non-compliance. And confusion, as they get bombarded with nutritional misinformation from all ends. It is unrealistic, and not a practical change.

They need to get educated, too, in communicating information with teenage and adult, anorexic girls and young men. Statements like “great job! Your weight’s heading right up there!” or “You need to gain weight or you won’t get your period” can be traumatizing. Or “You’re perfect—don’t gain another pound!” And how many girls couldn’t care less about getting their periods? Telling a 12 year old that not getting a period will lead to osteoporosis? Who cares? They envision old, bent over, great-grandmothers—not something they believe can happen to them in their teen years. But tell them amenorrhea could cause fractures when running or engaging in their favorite sports, requiring them to end participating in sports with their friends—now that may make a difference.

What’s In It For You?

Listening to what patients really do care about, about where their concerns lie, will help motivate change. For some, it’s about hair loss in clumps, or lanugo, hair growth on their arms or face, as their weight has dropped, that concerns them. Or it’s being freezing all the time, as their body temperature has dropped. Or the fear they will not be able to return to soccer, or dance, or field hockey, to name a few.

Sure, doctors and health care providers get frustrated by non-compliance. But our patients are no less frustrated—and they’re angry, and hurt—too. Because they are not understood; because there are good reasons they stay stuck in their unhealthy behaviors. And it is rarely due to ignorance.

Advice For Fellow Healthcare Providers

Compliance shouldn’t be the goal we shoot for. Patients need to be more than puppets nodding and acting according to our commands. (See definition of compliance.) 

They need to be engaged in the process of change, participating in charting their course. We all need supports, guidance, and compassion, not just rules, to begin making change. Oh, and did I mention the need for hope? Certainly, if I don’t believe in my patients, they won’t believe in their own potential for change.

The health system isn’t going to get over-hauled any time soon. Seventeen minutes may seem like a luxury in the future. But if only doctors and other providers would take the time to ask a few key questions. And then? Give up a few minutes of the 17 to truly listen.

Then they can refer to appropriate providers—the nutritionists and therapists experienced in a behavioral approach to change. Only then can they assist their patients in making change, helping us all feel a lot less frustrated.

Taking Charge: Practical Strategies for Enjoying Holiday Eating and the Morning After

Ready to take control?

You, my readers, are a diverse bunch. Some of you are overweight, perhaps higher than your usual and healthy weight. You struggle to have balance in your eating—to eat what you’d like, and to learn to eat just enough. Others maintain their weight in a healthy range, yet grapple with these very same issues. Just because you may look fine, doesn’t mean you’re not challenging yourself to improve your relationship with food. You, too, may be working on legalizing foods, moving from a diet mentality.

Many of you are underweight, as evidenced not only by the scale, but by your body’s function—your low heart rate, body temperature, or hormone levels, resulting from inappropriate weight loss, food restriction or over-exercise. You too may be trying to release yourself from the grips of disordered thoughts and behaviors around food, whether or not it is visible to those around you.

Yet as diverse as you are, it seems most everyone gets challenged around holiday and social eating situations. Social anxiety may add flames to the fire. But I’ll leave that to the therapist bloggers to better address.

Last November, I did a post on recovering after slips, such as after Thanksgiving. Now I’m realizing I’d better address prevention. Perhaps I should have thought of this sooner? It’s not too late! (For those non-US residents, plug in Christmas, Hanukah, Kwanza or any other social eating situations not connected to a holiday celebration—the situation is the same.)

It may seem strange, but regardless of what end of the scale you’re on, or what your personal needs are— weight loss or gain or stabilization—these guidelines apply. Because we all want a sense of control over our situation—to eat what we’d like and eat enough of it—but not too much; to enjoy eating and feel entitled to eat, regardless of our size, in spite of the opinions of others; we’d like to free ourselves, discarding those useless rules around good food/bad food, appropriate times, and inappropriate times to consume food.

So here are my tips:

Maintain normalcy before the gathering.

Don’t skimp on your eating beforehand or you’ll be more vulnerable at the event. All too often I’m told of a client’s attempt to prevent overeating. What do they do? They eat less before the meal out or the function, figuring they’ll save some calories. Then they arrive more vulnerable than anticipated. As a result, their resolve to mindfully select their food, or to pace themselves through the afternoon of eating goes out the window.

The sensory stimulus doesn’t help.  The pleasant aromas and visual displays of appetizers through desserts calls to us. Their strategy backfires, and they feel a sense of hopelessness with getting their control back.

Using your head to maintain the necessary balance

Or like my patient, Shari, you restrict before the event, eat fine or over eat at the event, then restrict again afterwards. Hmm. Does this make sense? Somehow, when you hear it told about Shari, it’s clear how senseless this is. Yet my clients believe that somehow they are different, that the rules don’t apply. They are smart. They get it. I know they do. Yet I frequently have to remind them they are not special; lovely individuals, yes. But not so unique that the system doesn’t apply to them.

Get informed. Ask questions.

"What will you be serving?" "What time will we be eating?" It helps having a sense of what to expect. Going to a friend or family’s home? Ask what you can bring—not if you can bring something. Perhaps you'll contribute something you really enjoy and feel good about eating. A lighter dessert? A favorite vegetable dish? An appetizer you’re comfortable eating?

Pre-plan.

It starts with inquiring about what’s being served. For some, it’s necessary to think through your options in advance. If you are dining out, consider checking the menu online, to be less overwhelmed with the decision making during the gathering. Going to family for a holiday meal? Hmmm, they’re serving 6 different starch choices, including mashed potatoes, stuffing, winter squash, sweet potato casserole, biscuits, and pumpkin bread. Which ones can I get at any time? Which ones are my favorites? Which ones should I just pass on, without regret?

Remember, it’s not your last chance to eat.  So if cranberry sauce is a favorite, plan to buy it and keep some at home. Add it to turkey sandwiches or make a turkey with the fixings, even when it’s not Thanksgiving or Christmas.

You don’t need a dog for a doggie bag. Plan to bring a piece of pie, or a package of leftovers for a later time. Perhaps you’ll get hungry again later that evening. You’ll better appreciate the leftovers when you are less full anyway.

Plate the appys.

Enjoy the appetizers. But know how much you are eating. Select what you’d like, and place them on a plate, together. This allows you to take note of what you are consuming. When we are simply grazing on them, without really seeing or acknowledging them, it is much easier to over eat.

Watch the alcohol.

Painting by Russell D'alessio, Bar Harbor, ME
I hope these women had eaten before their martinis!

Nothing decreases our awareness and inhibitions like alcohol. If you can drink responsibly, that’s fine. Best to delay your drinks until after you’ve had some solid food, though.

Be flexible*.

Maybe you decide you’d like something other than what you intended to eat. Or you ate more than you anticipated, even though you tried to be well prepared. The worst thing you can do is to beat your self up. Best to work on moving on. (Yes, it takes 3,500 surplus calories to gain a single pound.)

We may not be able to control senseless comments from those around us at family and social gatherings. And unless we are hosting, we can’t eliminate temptations. But we can certainly take charge of our own thoughts and actions. And in the worst-case scenario, remember it’s only one meal, or one day. So if you ate more than you needed and are sitting with regret, re-visit that old post on the morning after.

* Did you, like me, wish this subheading was left-justified, instead of over here on the right? It's the start of being flexible!

As always, I'd love to hear your thoughts!

Trust Yourself. Except When You Can’t Be Trusted.

6:04 PM

Hi Lori,

 Could I bother you for some support again?? Am *really* struggling with wanting to weigh myself. If you had a moment could you please remind me why this is not a good idea.

Wouldn't it be great if there were a similar warning posted above
your scale? TURN BACK NOW! Or face the consequences!

Here’s what I’ve got:

• It's  too high god knows what I’ll do – and that is not good for my safety
• If it’s where I want it to be or lower then ED is the one telling me how to feel
• I really do want to be rid of all this, and weighing myself will only prolong my recovery
• It will be 13 weeks tomorrow without weighing myself – and I’m proud of that
• I really feel that my recovery only started for real when I stopped weighing

Any other thoughts would be really gratefully appreciated

Thank you

And here was my response last night:

"I think you nailed it, PJ. Weighing yourself messes with your head. Not weighing yourself allows you to take charge a bit. Body mass doesn't change in 24 (or 72 hours) in any measurable way. But changes in weight may reflect bowel function, hydration, menstrual status, fluid retention, to name a few. It takes 3,500 calories per week (above whatever is required to maintain your weight) to gain a single pound, more than that if your metabolic rate is on its way up.

You are worth more than your weight in pounds (or kilos). Also, not weighing yourself may increase your anxiety. Be sure to acknowledge that and add some stress reduction (non-exercise focused) activities to help you cope."

This isn’t to say that nobody should weigh herself. It really depends on what your issue is and what kind of place you are in.

A 2005 study from a Brown University psychologist showed that regular weighing was associated with better maintenance of weight loss in an obese population of women. Perfect! I think I’ll start daily weighing, I bet you’re thinking. Not so fast, not so fast.

Lot's of steps before you reach your goals.
Is it worth it?

Weight management isn’t the only outcome we should be addressing. What about the impact, not on pounds, but on perceptions? Are you grounded enough that if the scale changes, yet you know in your heart you have been sticking to your goals and feeling in control of your eating behaviors, listening to and respecting your body, that you will be able to dismiss it as a senseless measure?

Or will this trigger more negative thoughts about your self, more obsessive thinking, and a sense of failure? If you are in a good place—grounded enough to roll with the scale fluctuations, which are sure to occur—you may be fine weighing your self. But please don’t make this decision on your own. Consult your supports.

First ask yourself “How will I feel if the results aren’t what I am expecting?” Am I truly more anxious not knowing my weight, or knowing it? Will it be destructive for me? If the answer is honestly no, then try the following.

Before getting on the scale, do a bit of a self-assessment. Ask yourself:

• Have I been honoring my hunger and eating when I need to?
• Have I been stopping when I’ve had enough, or when I’ve had what I think I should have based on unhealthy food rules I’m holding on to?        
• Am I respecting my activity goals, and listening to my body?
• Am I being honest with myself about my actions?
• How am I feeling? What positive changes have I made that I need to acknowledge?

And finally, have a plan before weighing. What do I know and plan to do differently, as a result of my self-assessment?

What can you take from my correspondence with PJ?

Here's the view from the top. Worth the trek? 

Like PJ, you probably have more sense than you realize. But if you are struggling with trust and feeling more vulnerable to your unhealthy behaviors, take a few pointers from her.

• Acknowledge you are struggling. 
• Whether you are working on weight restoration or are overweight and trying to lose weight and improve your relationship with food, be realistic. Change isn’t linear. In other words, there will be ups and down, progress and slips, moments of strength and times of hopelessness. That’s what recovery really looks like.
•  Reach out and ask for what you need. Not everyone around you is supportive, however (I’m sure you can provide plenty of examples for us!) So call, email, text, post an S.O.S. to those you feel you can count on.

Focus on what is in place. And make a plan for changing what needs to be changed.

Thanks, PJ, for allowing me to share this! 

Please add your thoughts and experiences to the comments. Looking forward to hearing from readers.

Lessons About Eating From the Big Apple Circus

Beyond popcorn and cotton candy.

Thanks, Ethan and Sherrie for tolerating my need to photograph!

Controlling popcorn portions? Canning the cotton candy? No, this post isn't going there. Rather, last Sunday's clowns, contortionists, jugglers and acrocrobats  at the Big Apple Circus unexpectedly provided great blog material. I had no plans to do a circus post. Really. But I did take my camera. 

Truly the greatest show on earth!

It raised so many valuable and truly essential lessons about eating and eating disorder recovery, I simply had to share. Yes, much more critical than guidance on high sugar, high salt snack control!

Sticking to your plan 100% versus being flexible depends on your situation.

I'm not into extremes. I'm sure you'e guessed that by now. But if you're the trapezist or high wire act, there is no grey area. You've got to get it right, or else there are serious consequences. If the risk of a hospitalization is looming near, there's little wiggle room regarding staying on track. But if you're the juggler and you drop the cones or batons, life goes on, with less impact. The sooner you pick them up and move on, the less damage will be done. The longer you wallow in your disappointments, the harder it is to get your act together.

And after you slip, remember to pick your self up, with grace.  Slips happen!

And, you'll still get applause. Yes, even metaphorically, in real life.

The sooner you get back on track, the easier, both physically and psychologically. If you see your slip as an irreversible failure and give up, it becomes a self-fulfilling prophecy. The acrobat who repeatedly messed up throughout the first half was clearly losing faith in himself. And as a result, I had come to expect him to fail. But he started the second half with a restored confidence and was amazing. Believing in himself allowed him to turn things 180 degrees. And rather than dwelling on his slips, the audience praised him with the loudest applause at the end.

Be flexible, within your limits. 

Simply awesome!

If you are new to being flexible, don't start with a split! It may be enough of a struggle to take in all that you need to eat, even if you need to stick with only foods that feel safe. As long as you are medically safe, try one small change at a time. For some, flexibility comes more naturally, like for contortionists. Truthfully, no amount of practice and stretching will enable me to put my torso between my legs. But be patient. Learning to eat, sometimes for the first time, really takes time. Even breastfeeding has a learning curve you realize! 

Use your supports

Hooray! I got to chat with Grandma, aka Barry Lubin, my favorite clown
who in spite of all he's gone through continues to make us all smile!

There was such a clever, yet simple, most touching act. One of the clowns, seemingly lacking confidence, pulled out a small box which fit in his hand, with a hinged cover. Whenever there was enthusiastic applause, he'd quickly pull out the box and open it. Through his pantomime, he'd encourage more applause, and when it reached its peak, he'd abruptly close the cover. He had stored the applause, the positive reinforcement of cheers of support in his little box to carry with him. I loved the concept. 

How can we carry the positive messages, the counter to our negative feelings and discouragement when we are away from our treatment team, or our friends and supports? Maybe we could find our own symbolic hinged box.

Set realistic goals

Think tortoise. Sometimes progress is being stable or very slow moving. Sometimes you have to accept that it was enough to give yourself permission to respond to your hunger. But perhaps including new foods will take awhile. Goals will vary with where you are in recovery, how long you've been working at this, and if you've got a tiger mom on your team!

It's ok to be real

Reason to be pleased with himself!

Less sad about his mess-up then his fnger!

Not only is it okay, but to me it seems essential to cry when you're hurting and beam when you're proud of your accomplishments. And sometimes it's necessary to laugh at your self and the absurdity of your thoughts. We need to do a lot more of that.

Expect the unexpected 

A goat riding a horse was a new one for me. Shouldn't rock anyone's boat, so to speak, but neither should adding a serving of carbs or fat, when you come right down to it. Sometimes you'll need to make changes that you never expected to have to make. Like giving yourself permission to enjoy (yes, enjoy) a piece of cake!

Couldn't resist, in spite of the blur from lack of flash!

Personally, I'm glad I allowed myself to to go to the circus for my own pleasure, even at 48 years old without a toddler in tow! (although I did feel compelled to bring along my baby, now almost 20 years). And the Big Apple Circus is just as fun and meaningful as when you're very young.

Running Off the Carrot Cake? There’s Gotta Be a Better Way.

Okay, Plain Jane, your question was a great one (in the comments section of Recovering from Holiday Slips: Practical Strategies for Moving On), and deserves more that a one line response.

Plain Jane said...

 But, if we do eat more than we would normally, is it okay to exercise more to compensate? Isn't this a sensible way of preventing weight gain at these times? I'm struggling to understand how to just sit calmly by when I feel full and think 'oh it's okay, I won't gain any weight' (you have talked before about how many extra calories are needed for weight gain, but that doesn't seem to hold true for me. It seems anything I eat without exercising causes weight gain).

I bet this thought has crossed many a reader’s minds. And having just had my comment be the focus of another blogger’s post (see ED Bites), I thought I’d do the same. So here goes.

No, I don't recommend increasing your activity to compensate. This can easily spiral into compulsive exercise habits. You know the pattern—overeat, over-exercise, get too hungry, overeat, over-exercise—with a bit of restrictive eating thrown in. With increased activity, you'll find yourself hungrier sometime after exercising (generally after 40 or 45 minutes after exercising). But you're likely to not trust your self, not believing that listening to that hunger is okay (because you're still focused on the fact that you already ate too much).

So how do you manage to regulate weight, then? By listening to your fullness. Okay, true personal insights, from today.

I baked a cake, a delectable carrot cake with cream cheese frosting, in honor of my husband’s birthday. Let’s be honest. I wanted some delicious cake to eat, too. The birthday was just a convenient excuse. But more about the cake later. I had a hefty slice, I might admit, certainly more than I needed. And it was good. But a mere 1 ½ hours later we were expected at our friends’ home for dinner. And so we went. And we ate the traditional Christmas meal of Jews around the world—Chinese food. And then they served desserts, to celebrate my husband’s birthday.

I was minimally hungry by the time dinner was served, so what happened? I ate less than I would have normally. It’s not that I was calculating my intake, but merely acknowledging the feeling of my jean’s waistband. (And these were my very comfortable jeans!) And when dessert was served, quite frankly, I had absolutely no interest. I was full, and I knew it. And I knew that ¾ of the carrot cake remained at home. And I knew that if I should get hungry later, and should choose to satisfy that hunger with cake, that was an option. See where I’m going with this? 

If you eat more than you need, and you are listening to your fullness, you’re likely to make up for the excess simply based on how you feel. You’ll find your self less hungry, and if you are listening to your body and it’s signals you’ll eat less later. Hard to believe, but it really works. That is, unless you allow destructive thinking and negative self-talk to take over, sabotaging your recovery.

No, I won’t double up on the spin classes tomorrow. But I won’t leave the cake wrapped in plastic wrap on the kitchen counter either! I’m still feeling a bit full, but the feeling is passing. As I knew it would. As you know it does.

One more thing to address is the weighing. If you’re weighing yourself regularly, frequently, compulsively, in all likelihood you are not measuring changes in body mass. Rather, you’re seeing fluctuations in hydration, or other influences such as bowel changes. Perhaps the worst thing to do when you are struggling with feeling uneasy about how much you’ve eaten is to weigh yourself.

Remember—reassure your self that the fullness passes, that a large meal or snack has an insignificant, not-even-measurable impact on your weight. Don’t let your thoughts mislead you! Try to trust this process. It really does work, if you allow it to!

Here’s an offer for official “Followers”

• Send in a question or topic you’d like to have addressed. Once a month I will select one to blog about.
• Email me for the cake recipe! It was modified (as is my norm) from 3 different versions to a delicious recipe, healthier, though still requiring attention to portions!
• Not a Follower yet? Shy? Sign up with a made-up name/identity. Rather liberating! It’s a way of thanking me for free information, and letting me know you care!
• By the way, for the past 7 months I have sent out email welcome notes, after followers joined. I just found out that none have been received. So welcome, followers, and thank you all for reading, commenting, and sharing the blog with others! I do hope to figure out this little glitch soon!