Knowing When to Change Direction. A Case Study.

Laura wasn’t gaining weight, and I was puzzled. Now most practitioners who have been working with eating disorder patients might laugh at me and call me naïve. She has anorexia, after all! How odd is it for her not to be gaining weight, when you think she’s eating all that she tells you? You can’t trust the eating disorder!

Here’s the backdrop.

Laura, a woman in her early thirties, had struggled with anorexia for years before first seeing me. She was painfully honest about her unsuccessful attempts to eat amounts we had agreed upon, to follow a plan we had negotiated. At times she made some progress with eating a bit more but it was never sustained enough to change her weight or her health. And in between she cycled through numerous hospitalizations and eating disorder programs.

Several months had gone by and Laura was now in a very different place. She had shifted her will, in favor of recovery, of change. She asked great questions in our sessions and strategized about practical changes to boost her food intake. There was a notable change in her food records, which supported what I was hearing in my office. I was impressed by both her determination and the significant increase in food she had reported eating.

Yet Laura wasn’t gaining weight.

So I called her doctor, the best MD around for eating disorders. I told her it just wasn’t adding up. Yes, she reminded me that Laura has a long history with this eating disorder, and that I shouldn’t forget this. But, she trusted me and accepted, albeit reluctantly, my recommendation for a GI consult. If there were no clinical explanations for the lack of weight gain in spite of her reported intake, than I’d accept my foolishness in believing, in having some faith in this patient.

Following the procedure, the gastroenterologist report read like none I had ever seen. As head of a GI department, with a specialty in celiac disease, he stated that never before had he seen such a progressed case of celiac disease. Celiac disease is an intolerance to a protein called gluten found in many grains and foods, including wheat, barley, and rye. Gluten is also found to contaminate grains, showing up where it shouldn’t occur. For those with celiac, taking in gluten causes damage to the intestine’s ability to absorb nutrients, and results in discomfort and often weight loss and other consequences.)

Despite eating all she was eating, her body was unable to use most of these calories.  Her reports of eating were likely not exaggerated. And so for many months Laura followed the prescribed celiac diet, a gluten free plan, and finally began to gain weight as expected.

But it's going to take some work!

But the story doesn’t end here. When you have a medical condition, everyone, perhaps including you, assumes that everything you experience is the result of your condition. It took some convincing that Laura was seemingly eating what she said, and that there could be something else going on. As a person living with MS, I have to remind myself this all the time. I could have pain or numbness because I did something in my workout, not just because I live with a neurological disease. Similarly, Laura had two conditions—one of which managed to get missed, because we were all so focused on the other one.

The reverse is also true. Just because we knew Laura had celiac disease, didn’t mean that her lapses in progress with weight restoration were directly linked to her celiac disease. Sometimes they were, the direct result of restrictive eating.  And sometimes the two diseases were linked, like when her eating disorder side sabotaged her recovery and chose to eat gluten-containing foods, leading to more malabsorption and poor weight gain.

Laura’s case is rather atypical. But there’s a lot we can learn from it. We, all of us, need to watch our assumptions. We are quick to attribute everything to a single condition—and that includes obesity, as well as eating disorders. Remember that post where I shared I have high blood pressure http://dropitandeat.blogspot.com/2011/04/lies-theyre-feeding-you-about-your.html? Yes, in spite of my normal weight and active lifestyle, I take meds for hypertension, as did my slim father.

Not giving up, just respecting his limits, acknowledging when
it's time to slow down.

That being said, even medical conditions, including eating disorders, can be changed, so don't give up! No, there’s no medication to resolve it, but even individuals like Laura, and like Jamie http://dropitandeat.blogspot.com/2010/09/insanity-or-recovery.html dealing with anorexia and bulimia and Maggie http://dropitandeat.blogspot.com/2011/02/maggies-152-lbs-weight-lossthis-time.html and Erin http://dropitandeat.blogspot.com/2010/09/meg-hit-300-pounds-wednesday-and-was.html dealing with binge eating disorder, with significant obesity for most of their lives before changing it, can recover. 

It takes some faith in your self and some good supports, including a treatment team that believes you can move on. And a willingness to change course when you need to—to learn how to manage obstacles, to explore additional therapies and levels of care that might get you over a hurdle.

I wouldn't have married him if he couldn't find a better solution!

And now?

Laura has had her share of ups and downs over the many years I have worked with her. But she is the best I have ever seen her. And she wanted me to share her story with my readers. I continue to try to support her as she balances her newfound interest in food and eating (including foods such as lasagna) with guidance for preparing such foods gluten free.

Summer Wheatberry Salad. My Favorite!

The finished product!

It’s hard to say what I like best about this wheatberry salad. I love the chewiness of the wheat berries and dried fruit, combined with the crunch of the celery and the pecans. There’s the sweetness from the orange juice, dried cranberries and drizzle of honey, that’s just sweet enough, countered by the vinaigrette and zing of the orange zest.

And then there’s the fact that it’s easy to make, and can serve as a side dish with dinner, or stand alone as the main dish at lunch. And did I mention that everyone loves it? It’s also a great source of fiber (about 6 grams per serving).

This is one of my favorite salads for the warm weather season. And yes, I realize it’s still springtime, but this recipe so reminds me of summer!

Enjoy!

Summer Wheatberry Salad Recipe

Serves approximately 12 (just about 1 cup per serving)

This is more scallion than you'll need!

Ingredients

2 cups dry wheatberries (also called hard red wheat berries) (will make 6 cups cooked wheat berries)
3 Tbsps. olive oil
1 cup orange juice
1 large tart apple, chopped, skin on (such as Granny Smith)
1 cup fresh mint (spearmint), chopped
4 celery sticks, diced
4 scallions (green onion), green and white parts, chopped
¾ cup pecans
1 cup craisins (sweetened dried cranberries)
¼ cup vinegar (red wine or apple cider)
1 tsp salt
1- 1 1/2 Tbsp honey (to taste)
orange zest from one whole orange

Fresh mint from my garden. The only thing I manage to grow well!

Consider adding chopped red peppers, red onion or additional celery for more crunch and larger volume per serving.

1. Cook the wheatberries. Place the wheatberries into 6 cups of boiling water. Cook, uncovered, over low heat for 45 minutes, until soft and chewy. Drain.
2. Place drained wheatberries in a large bowl. 
3. Add all ingredients and mix thoroughly.
4. Refrigerate. Serve cold or at room temperature.

How do I count this on an exchange plan? For a full cup this satisfies 2 grains and 2 fats. Toss in some grilled chicken to help round off the meal.

Time to Clear My Plate. Before You Get Triggered by My Plate, Read This.

Oh, Michelle, I so appreciate your honest and passionate concern for improving the health of our nation, particularly our kids. Really I do! But quite frankly, the subtle messages conveyed through the new USDA My Plate set us way back in our progress.

That’s not to say that I find nothing favorable about it. I do like the bright colors (they make me feel like a kid again), and the concept of half the plate as fruits and vegetables is truly a helpful, and reasonable teaching visual. And, a message I can support. But here’s where we part.

Where are the fats?

Ok, I realize that in the written food group description fats get mentioned, but not encouraged. And let’s face it—it’s the visual image that makes the biggest impact. And in that regard, fats are absent. Yes, in spite of the latest Dietary Guidelines for Americans summarizing the enormous body of research and declaring that increasing (unsaturated) fats should be a goal, comprising up to 30% of all our calories, this message is lost in My Plate.

In fact, in the description accompanying the image, it even sheds a negative light, saying “oils are not a food group”. And by oils they really mean fats, because avocado, for instance is not oil. Funny, in past pyramids, such as 2005, fats were a distinct part of the pyramid and were scattered around as a component of the other food groups. And if fats are not a food group, why is protein? If I remember my basic nutrition way back the three macronutritent groups making up all foods are protein, fats and carbohydrate. Yet My Plate places the nutrient protein on the plate, a component of foods, as if it’s a food, yet states that fats have no place? I don’t get it.

Where’s my favorite food group?

But perhaps the biggest problem I have is the omission of those “empty calorie” villains, the “sweets”. Past health messages from the American Dietetics Association and the recent aforementioned Dietary Guidelines for Americans 2010 instructs us to “find balance between food and physical activity.” At no point do they suggest we should eliminate sweets to prevent obesity.

And speaking of those additional calories, why make such an overreaching statement like “Enjoy your food, but eat less”? Should I suggest this to my normal weight sons? To the healthy growing kids I see? To the many I work with struggling with trusting their hunger, many of whom are working hard to increase their calories by appropriately eating more? Should I be eating less as I’m training for a biking event this month? Such an unnecessary and detrimental generalization! Would it take an eating disordered child for Michelle to be more sensitive to such absurd health recommendations?

This dietitian endorses a health-promoting message to include junk food!

Here’s the scoop. Black and white messages about good foods to eat and bad foods to avoid are damaging. They contribute to society being misinformed about weight management, and about eating in a healthy, balanced and pleasurable way. In life kids and adults are going to eat cupcakes and chocolate and ice cream in all flavors. The problem won’t be that we’re eating these foods. It’s that we view them as bad, feel guilty, and end up overeating them, because we have been convinced that we have done wrong by consuming them—in any amount. Rigid rules and clear omissions teach us nothing. They reinforce the wrong messages. It’s time to get with the times.

Why the beef about dairy?

And to the critics of inclusion of a dairy serving, like Walter Willet at Harvard (who says there’s no evidence to support including a dairy requirement), I’d like to ask you this—are you thinking we’re going to meet our requirement for calcium and Vitamin D from sardines, canned salmon, almonds and broccoli? I don’t think so. Perhaps the USDA could have done better by broadening that category to say “milk and fortified soy milk”; no other non-dairy alternative provides as much protein as well as calcium and Vit D. Yes, there is evidence that we need an adequate intake of these two nutrients, and practical, economical, acceptable sources are few and far between outside of dairy products.

As for the interactive resources, I would love to share my thoughts. But after signing in, the program failed to work when I tried to explore the physical activity section.

Time to go eat. 

My plate will include some homemade waffles this morning, fruit, yogurt, and real Vermont, full sugar maple syrup. And I just might decide to include a piece of pastry for my afternoon snack. And in spite of what My Plate urges, I have no intentions of reducing my portions from their usual level!

Thanks for reading! Enjoy your sweets today.