Are You Still Thinking It’s All About Your Weight?

You’re a mixed crowd, dear readers. You are patients, current and past, local and those I Skype with overseas. And you are Anonymous followers whose identity I’ll never know. You are largely female, but include many a loyal male reader. You cover most ages from late teens to into your 70s. On a recent day you visited from all 50 US states (a first!). And you regularly read from all continents. 

I love this! 

I certainly don’t know you well, except for what you share in your comments and emails. You may struggle with an eating disorder of any variety or strive to maintain your sanity in a world of over focus on food rules and misinformation.

You may be underweight or overweight—whatever those terms have come to mean—and you may or may not have come to terms with the work that needs to be done. You may be simply contemplating change or you may be working on maintenance and relapse management.

Yet here’s one thing I know for sure: your weight is not a valid measure of your progress nor of your effort, of your commitment to change or your need for change.

The past couple of weeks I’ve had many an encounter that convinced me I needed to share these thoughts with you.

Here’s a sampling of what I heard this week:

• She was frustrated by her stabilized weight—it was nothing like those weight loss ads promise! Yet she realized that she is now capable of eating a couple of Oreo cookies. Justa couple—and feeling satisfied. And, she was able to talk about it, as opposed to keeping this info a secret. No more Oreos in the closet.
• There was the realization that food tastes good! From someone who has spent the past umpteen years eating while barely using her senses (similar to how she was living life) this was a giant accomplishment. She now appreciates what she likes, and can follow her preferences. And she can allow herself this pleasure long denied.

• “Do you mind if I eat in our session?” she asked me, as she nonchalantly pulled out her McDonald’s French fries. “I haven’t had time for lunch yet”. Long ago when we started our work together, reliance on a meal plan was absolute and deviating from the plan was a non-option. Food was restricted and binging was common. Think what you might about fast food, seeing this meal enjoyed, and eaten normally, made me happier than I’ve ever imagined a McMeal might!

• He is learning to reframe his actions. Instead of, “I only walked 3 times this week, for only 10 minutes”, I can, with a mere raise of an eyebrow have him shift his focus. “I walked threetimes this week! I’ve started to make walking a priority to help my blood sugar! And it’s feeling good.”
• Black and white thinkers may still struggle with what I refer to as the what the heck effect, that sense of why bother I’ve already ruined it. Yet even their acknowledgement that the thinking is the culprit, not the food item, is a major and necessary shift.
• And finally there was this list I received from Dana just yesterday:

First I'd like to begin with the positive changes I have made since under your care:

    -I'm not starving myself

    -I'm throwing up TONS less

    -I do NOT exercise, ever

    -I incorporate risk foods into my diet

    -ed thoughts no longer consume 100% of my brain

    -buffets are "manageable"

    -I allow myself to eat after dinner

    -I no longer consume bottles and bottles of diet coke/day, just 1 or 2 glasses

    -I only drink 2 cups of coffee/day - not 2 pots

    -I DRINK calories!!!!!!!!

    -I allow myself to snack in between meals

    -I can go to dinner with my friends now with very little anxiety

    -I eat in front of people with more ease

    -I can control binges with much greater power

    -I recognize and honor my hunger now

    -I have learned to speak up a little more

    -I am present

    

 I know there's a LOT more to that list, but those were the ones at the top of my head.

Proud Tiger Mom and her cub, taking her
French pastries home after a satisfying brunch.

I feel like a proud Tiger Mom. Really.

In each of these cases, focusing on weight as the end point would have been absurd. In Dana’s case, weight has been around the same for probably a year. Why probably? Because honestly I rarely obtain it. But the times I do, it never surprises me. I’m not blindsided by positive talk without substance. And I ensure my patients are following up with their physicians for medical checks when necessary.

Weight can be stable or in a normal range while binging and purging. It can be stable while restricting followed by rebound overeating. And weight can be outside the “healthy” BMI range with either healthy or unhealthy diet and behaviors. What a disaster it would be then to focus on weight without attention to the damaging behaviors!

Just the setting for enjoying a pastry out!

Weight assessment certainly has its place. A progressive shift in an unhealthy direction (for an individual’s need) is clearly a red flag. But without assessing the underlying thoughts as well as the behaviors, obtaining and focusing on weight is nothing short of damaging.

I'd love to hear how your thoughts and actions have shifted, so please share!

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.

My High Calorie Intake Could Make Me Forgetful?

A Response to the Mayo Clinic's Press Release on Overeating and MCI


UPDATE! Read the response in "comments" from the primary investigator!

Yes I'm distressed!

I'm pretty worked up right now. Could be because the media is suggesting I should eat less, and I don't like it when I'm told to eat less—particularly for no good reason. And maybe it's because I take my mental function seriously, particularly living with Multiple Sclerosis, which can impact cognitive function. So best not to make unsubstantiated claims about what's gonna impact things like my memory unless it comes from good, solid science.

I'm perplexed. Could I really be the only one who sees the great irony in the opening statement of this Mayo Clinic press release stating that higher calorie intake, as self-reported by those with memory loss, ages 70-89, is associated with greater mild cognitive impairment (MCI)? Under the title Overeating May Double The Risk Of Memory Loss  the authors conclude "Cutting calories…may …prevent memory loss as we age." The study suggests that eating "too much" (more than 2,143 calories) may double the risk of memory loss.

Yes, the very people assessed to have the worse cognitive function reported the highest, sometimes extremely and unbelievably high calorie intakes. And as the press release video reveals, we're talking significant impairment (as in “Oh my, I've forgotten I was supposed to fly to New York yesterday" — oops!)

"Vell, I believe I had a couple of chickens, a pinch of shmaltz,
a few spoons of potatoes and a pint of borsht."

It's well established that self reporting dietary intake is full of errors—generally, the underweight err on the side of over-representing food intake, while the overweight do just the opposite. But self-reporting by the cognitively impaired? Is this some sort of joke, an April Fool's prank come early?

Even self-reported food intake using a validated assessment tool has its faults. (As in the Harvard study.) Being validated does not mean that the findings are real, that they reflect what was truly eaten. It merely addresses reproducibility. In this Mayo Clinic study, the only thing that was truly confirmed (as reported in the press release) is the degree of impairment, as assessed by more than one source. So we know participants are truly cognitively impaired, but we don't know with certainty how much they really ate calorically in the preceding year they were reporting on. Quite the population for accurately reporting, retrospectively, the amount they ate!

Maybe, given their MCI, they've forgotten how many portions they really consumed? Or perhaps they forgot that we typically don't report these things honestly.

The Joke is on Us

So here's my beef. The Mayo Clinic's press release, and subsequently the media outlets which picked it up, misled us. Even if my reasoning is off and all of the potential places where the science seems shabby were fully explained in the full study (which is yet to be released) there remains this problem—the media's conclusions suggest causation when at best we have an unexplained association.

The research summary states that higher calorie intake is associated with more cognitive loss (but does not necessarily cause it). So to then conclude, as most every article has, that we should be reducing our food intake, “cut out the chips” even, limiting our calories to prevent memory loss couldn't be more absurd! How unreasonable to manipulate us with these faulty one-liners, these irresponsible conclusions.

The Real Answer May Lie With BMI

The study controls for variables that might otherwise have confounded or confused the results. The researchers appropriately ensured that the finding, the increase in MCI with higher calorie intake, was not the result of such variables as diabetes, stroke, and, important to this argument, BMI. In other words, if I understand the press release and study abstract correctly, the increase in MCI associated with increased calorie intake at the highest intake levels, was not due to BMI. So BMI would not have been similarly increasing along with the cognitive impairment. Or, for that matter, with caloric intake.

So here's where I run into some difficulty. The study is stating that some, manyindividuals ages 70-89 years, are consuming > 2,000 to 6,000 calories daily, if we believe what they self-reported. And this is not linked with increasing BMI? If it isn't, that means people eating a rather extraordinary amount of food have no higher BMI than those at lower intakes. Soooo, if they are eating so much, but don't have higher BMIs, than how do we explain this?

There are several possible explanations. They could be expending more calories from exercise. Yet from the abstract, there was no mention of activity level—a major omission if we are assessing intake and making claims regarding the effects of intake without exploring output. Maybe it's exercisethat's linked with MCI, for goodness sake, as exercisers would need to be eating at higher calorie levels. “Exercise Causes Cognitive Impairment.”  Wouldn't that make for a headline!

Or, maybe there is some other medical explanation for such high intakes without resultant higher BMI. Are they malabsorbing—as in such conditions as celiac disease? This would result in nutrient deficiencies, which certainly may be responsible for cognitive losses.

Or maybe they have some thyroid condition, or cancer, not yet diagnosed, which may account for greater expenditure of calories, and may also impact cognitive function. I am no expert on memory loss—that I can say with certainty. But it appears the researchers have not done due diligence regarding their study and its conclusions.

In fairness, all the answers may be in the full research paper, yet to be published. Yes, I requested it, but was only presented with the abstract and the press release; even my questions regarding exercise were ignored.

Even referring to the higher calorie intake as “excessive” or "overeating", leaves me scratching my head—on what grounds? If you are more active than your peers at 75 years old—still playing tennis, walking regularly, golfing in your retirement years, even hiking as I've seen many a 70 and 80 year old do—wouldn't you need to be consuming more calories? Why should they be labeling this higher intake excessive, unless it is resulting in an undesirable weight increase outside of their normal range? But I didn't see this addressed in either the abstract or the press release.

And why should you care?

You, my readers, do not match the profile of the study participants in terms of age. But you are being irresponsibly told that lower calorie intake may prevent cognitive failure. And when it comes from a reputable establishment such as the Mayo Clinic, and sealed as a reality in the written word of such media outlets as the Wall Street Journal, Time Online, and others, you'll believe it.

You'll believe that higher calorie intake is detrimental—regardless of your caloric need. And then another study may arise (like the Harvard study) drawing similarly inappropriate conclusions, and you'll buy into those senseless conclusions, too. And soon you'll be so inundated with all this "science" that you'll be overwhelmed about what you can eat and what you should avoid and how much. See the problem?

What can you do? Don't be too quick to accept the written word as fact. Await a follow up study that might confirm findings. And be careful about where you get your information. Sure, reputable resources are better than sites promoting and selling something, with a financial interest in convincing you of the value of their words. But even seemingly solid institutions and individuals can draw the wrong conclusions. When in doubt, discuss such articles with those capable of shedding some light on the findings.

The unfortunate end result of early publication of scientific studies is a loss of trust. Studies that haven't yet made it for publication in peer-reviewed journals have no place in the hands of the public. Misinformation runs rampant, and as consumers of this information, we are left overwhelmed and confused. And it's a bad state of things when we can't trust science.