A New Study about Low Carbohydrate Diets: A Study in Irresponsible Journalism

An article in the New York Times recently reported the health benefits of a low carbohydrate diet. The article attempted to explain the importance of such a finding and balance it within the current medical knowledge about nutrition and health.
Instead, this article reinforced that journalists need to better understand the influence of such a piece on the public at large. Many people will use this study to justify disordered eating and strict decision-making around food and health. Influential media need to heed their own power and adjust their reporting accordingly.

The article summarized the findings of a study in a respectable medical journal as follows: a diet comprised of low carbohydrates and high unsaturated fats appears to have improved health outcomes, especially cardiovascular health.

On the surface, a few simple conclusions seem harmless and perhaps even useful for a population eager for guidance on nutrition, but newspapers, desperate for an uptick in unique views and ad revenue, need to understand the way the public will interpret these conclusions.

The article surprisingly suggests that few people will heed this information, but that is clearly untrue. A stamp of approval by this newspaper immediately turns reasoned, balanced conclusions into fact for the public.

For a readership already plagued by confusing nutrition information and a terror of obesity and eating disorders, new, far reaching conclusions from a study the public is not educated to interpret only worsen the fear for the normal eater, who now will believe carbohydrates to be an evil food.

The newspaper needed to expound on the significant limitations of such a study. On first glance, the research has four glaring concerns which limit the utility of the conclusions. I imagine a more indepth analysis of this research would reveal many more.

The first is that the researchers have no way of proving that each subject followed the prescribed diet, and, in fact, research into dietary studies has repeatedly shown that people do not report diets faithfully. They tend to alter food diaries to reflect what they want the researchers to see rather than the truth. This is a common issue with studies about nutrition but must also be acknowledged.

Second, it is almost impossible to factor out all possible reasons for improved health and single out a change in diet as the cause. Making broad medical conclusions from a dietary change is hard to prove in subjects of a study and thus risky to propose, especially for information so desperately sought after, and then followed, by the public.

Third, changing one's diet for one year is nowhere near long enough to make any overall conclusions. The relationship between diet and a lifetime of health is broad and the information available is inconclusive. In order to have real value, a study will need to track health over a much longer period of time and will need to attempt to factor out the many other causes of health problems. However, that is a long and expensive endeavor that this study did not attempt.

Last, over 95% of people who change their diet end the changes within two years, so the likelihood subjects will continue this diet once they are no longer tracked by the researchers is extremely low. Making any reasonable connection between the general public and a dietary change needs to take into account the current, accepted knowledge about how hard it is to maintain changes in one's eating habits over an extended period of time.

The desire for a quick-fix diet and for definitive data to choose a philosophy of eating as healthful is overwhelming. Confusion around endless food choice and unlimited, delectable eating options leaves most people unsure of how to eat each day. Instead, the latest diet craze, research conclusions or evil nutrient lead to the endless string of nutrition fads in recent decades.

With a plethora of knowledgeable, balanced journalists, this reputable paper needed balance the conclusions of one study with the irrefutable evidence that scientific knowledge of nutrition is limited and that a balanced diet is the best alternative. As many of their esteemed reporters have said, we are omnivores who survive best on a varied diet with more real food and less processed food eaten regularly through the day. Any other information presented as fact is, at this point in time, purely conjecture that needs much more extensive research to have medical value.

The media needs to understand its responsibility in presenting new nutritional information and translate the findings into valuable information for the general public.


Raising a Child in a World of Dieting Part II

It rails against everything parents know to say less is more in raising children.

The time and energy spent managing the success and future of a child leaves little room for the child's personal growth and exploration. Forget any concept of small successes and failures: these kids are praised moment to moment as if they invent electricity every other day.

No measure of success truly matters because it is the norm. In fact, many communities just create endless rounds of success for kids these days--trophies for everyone--and not a whit of criticism or room for improvement.

Perfectionism has become the expected way of life. Difficulty translates into difference. No one, parents included, can tolerate failure. Ever. 

For readers of this blog and, for that matter, any literature about eating disorders, this mindset will be very familiar. It describes to a tee one central personality trait for people with eating disorders. Motivation gone awry turns into overwhelmingly impossible standards.  Internal drive without reason or purpose makes people need a way to opt out of completely unrealistic goals. Life is too hard when the expectations are so unreasonable.

Instead kids find perfection another way, namely through manipulating food and weight. 

Parents also struggle to accept imperfections in their children. Just because each kid gets a trophy doesn't mean they're all equally good at the sport. Adults, even those taken by fantasies of wildly successful prodigy, see the writing on the wall sooner or later. Accepting that reality and realizing their child is just another imperfect person are not easy pills to swallow. 

When faced with this reality, parents can turn to food and weight just as much as children. The illusion of creating a perfect child because of correct eating and weight maintenance becomes very alluring. Part of that can be positive reinforcement by adults who approve of a child's body type, but an overweight child can cause concern in adults and lead parents to use weight loss as a goal with their child, as a way to perfect their offspring. 

Establishing food restriction and weight loss as central to a child's identity severely limits their personal growth and development as well. At a time when a child is learning about their place in the world, focusing on something so limiting and narrow as weight can quickly derail their maturing selves. 

In this realm, the goal of parents is to reinforce the personal qualities of that child, psychological, emotional and physical, while protecting the child from the collective forces trying to focus family energy on food and weight. A consistent message from parents can balance those outside pressures and ensure the child knows the alternatives that exist in understanding oneself. 

It can be very difficult for parents to brush off outside comments about their child's physical appearance, especially when critical. Aggressively defending one's child against those adults who make comments only gives their thoughts more credence. The key is to discredit their thoughts while always presenting another way to see the world. 

Consistency, clarity and balance can, over time, allow the child to learn different ways to balance food and weight in a different world philosophy. The idea is not to eliminate those messages that reflect body and weight obsession since parents don't have that kind of power. It's rather to provide an alternative that so that the child  knows there are more important things to life.


Raising a Child in a World of Dieting Part I

In the next two posts, I will switch gears to talk about parenting children about food and weight. Adult attitudes towards these topics are central to a child's understanding of self-perception and of her place in the world. It is one thing for adults to struggle with the role of weight in determining self-worth, but it's something entirely different to saddle a child with those thoughts from the get-go. 

It has become fully accepted that weight is one of the primary means to judge others and oneself. The bias against those who are overweight--and the similar overestimation of those who are underweight--runs rampant in our society. The less discussed caveat to the prejudice is that being overweight or underweight always reflects overeating or dieting, respectively.

Laden with judgment, this reflection represents the implied battle between gluttony vs. restraint and the basis for judgment on our moral character. 

The sad truth of our culture today is that changing this prejudice doesn't seem to be on our radar. Much of the writing about the general increase in obesity and eating disorders reflects changes in accessible food, the plague of dieting, acceptable body type and the drive for thinness, but these cultural changes don't stop us from fully believing the overarching bias. 

This attitude has now seeped its way into judging a parent's ability to raise a child. The increased interest in parenting techniques and the concept that children are a reflection of parents' success make weight an easy target for judgment. Parents of thin children gloat while hose of overweight children shrink away in shame. These tendencies all seem to ignore the general well being of the child. 

Parents heed the fear of an overweight child by focusing on the child's eating right away. Starting with parents' obsession with a baby's feeding patterns, they monitor food intake throughout childhood, first for health and wellness but gradually, with the communal bias in mind, for weight maintenance. The end result is that parents know they will be held responsible for any change in their child's weight. 

It's easy to see how the collective judgment can let a child's psychological development go awry. Childrens' bodies change constantly. As expert pediatricians explain, growth comes in fits and spurts, ups and downs. The message for a parent is to be ready for anything without expectations and certainly without judgment.

Varying growth will undoubtedly include changes in weight. At several stages of development, it is common for children to gain more weight: babies until they start walking and pre-puberty, for example.

Interestingly, some children can be underweight at those ages as well; however, others are likely to praise an underweight child rather than worry about adequate nutrition. Educating ourselves about a child's development--information easily at our fingertips--seems more valuable than judging a child and her parents based on a number on a scale. 

Falling into the trap of judgment sends a message to that child: there is something wrong with you. It isn't necessary to praise everything a child does, but it is imperative to allow her to believe she is capable, that she is not battling against an indelible mark against her. 

The clear step for parents is to figure out how to manage food, weight and health in a child's formative years based on the child's wellness, not the arbitrary worries of a community. Although the ill effects of outside judgment may be hard to bear, heeding those warnings is essential so as not to confuse or derail a child's psychological growth. 

The next post will address these concerns and give practical advice about how to monitor a child's well being.


Dieting, Metabolism and the Toll on our Lives

The central, common symptom of most eating disorders is chronic starvation. This is obvious for people with anorexia, but most patients who binge also feel like they must compensate regularly between binges by trying to restrict food as much as possible.

But even broader than eating disorders, it has become all too common for people to consider an inadequate intake of food to be the norm, if not superior to regular eating. And people often find praise in eating less and showing what is considered restraint, no matter how insufficient their meals. 

Extended periods of limited food intake affect how the body works. Without adequate energy to maintain and support healthy organ systems, the body sacrifices necessary function on many levels to compensate for the lack of energy. These sacrifices can span any organ, depending on the person, and can even become irreversible over an extended period of time. 

To much surprise, the metabolic effects of food restriction apply to overweight people as well. When people gain weight, their body becomes accustomed to a new normal weight range over time, so severely restricted food intake might lead to initial weight loss but then triggers the same metabolic reaction as it would for anyone. That sacrifice of organ function combined with shunting energy to basic needs are survival mechanisms. Ultimately, survival trumps the number on the scale every day for the human body. 

The combination of an endless supply of treats, all intended to increase food and economic consumption and the falsehoods of a diet industry leave much of he population at a loss as to how to eat. A significant percentage of the population is trying to diet every single day. Our metabolic reaction to these mixed messages render all extended food restriction pointless. The only real effect of dieting is a constant sense of failure. 

There's another insidious way chronic dieting invades our way of life, societal norms and pop culture. The expectation of many social communities is thinness at all costs. Much of the information from celebrities reinforces these same messages, as does any promotional photos that are photoshopped to reveal impossible looking bodies. 

Through my work to help people eat regularly again, I find myself fighting an uphill battle against constant and much more powerful messages outside my office from industry to celebrity to general norms. The ways to normalize food by returning to our roots of culture, meals and pleasure are typically drowned out by the endless ways society approaches food and weight. 

What is even more astonishing is realizing the extent of sacrifice in our lives and world. All the people who are chronically underfed cannot function at their top level. Hunger quickly turns off the most potent and creative parts of our mind and leaves us unproductive and unable to perform at our expected ability. 

It certainly appears that body and weight are more important than healthy bodies and highly functioning minds in our society, but I don't know if that is clear to the general public. 

I wonder if this message would have more impact than the current attempts to change how we eat. It feels like competing with the dieting maxims and convincing people to rest at their body's normal weight are ineffective. People need a clearer reason to see how we are constantly duped by a society bent on pushing us all to limit our lives because of a number on the scale.


Delusions of an Eating Disorder

Some recent posts have focused on the medical issues inherent in eating disorders. Classifying these illnesses as psychiatric belies the reality that disruptions in eating patterns trigger significant medical comorbidities, some obvious like vitamin deficiencies or osteoporosis, others less so like renal dysfunction or endocrine abnormalities. 

The classification system for eating disorders elucidates the more obvious psychological symptoms of these illnesses: feeling fat, the overwhelming need to restrict intake and the urge to lose weight no matter what cost. The sad reality of our current societal norms is that many people who don't have eating disorders espouse these beliefs, at least on the surface. 

The plethora of unrealistic, if not harmful, diets, cleanses, and reality weight loss shows points to the fact that eating disorders are only a step past what's considered perfectly reasonable in this day and age. It appears that the unlucky few who are genetically programmed to respond differently to an extended period of food restriction or overexercise cross the line into a disorder from the more typical disordered eating. The acceptance of disordered eating puts the susceptible ones at risk, but the drive for thinness makes those who get sick necessary casualties to satisfy our collective obsession. 

Despite the communal experience of food and weight, there are some psychological thought processes of eating disorders that step past what is considered reasonable and can even be seen as delusional, a fixed belief that is clearly false but unwavering. These thoughts often reside in the eating disorder of someone who is otherwise very practical, clear-headed and logical about life, someone even whom others seek out for guidance and advice. However, buried deeply under the rational facade is a host of thoughts about food and weight that is nonsensical and clearly untrue but guide that person's daily life. 

In these symptoms, the psychiatric nature of an eating disorder is abundantly clear. 

Common symptoms tend to involve the same basic premise that food is somehow detrimental for one's health and well-being. This thought process extends past a fear of foods, an idea that many diets and ill-advised nutrition research advocate, towards the attribution of an almost evil purpose to food. As that belief becomes more fixed, the natural response to avoid food and to feel that eating will jeopardize one's well-being is a natural, logical step. 

Once food is seen as the enemy and harmful, convincing someone that this thought is patently false becomes very challenging. It is so antithetical to people without eating disorders to view food in this way that someone with this kind of eating disorder seems very foreign and lives life very differently from other people and in fact differently from people with eating disorders who don't have these delusional thoughts. 

The process of realizing these thoughts are false takes time but is very possible in successful treatment. It's clear that other people don't view food in this way and that approaching food, something commensurate with healthy life, as harmful makes one's daily existence very difficult. There is a learning process to change deeply rooted behaviors associated with the delusion, but sustained challenges to old thought patterns can be very effective. 

These delusional thoughts are part of an illness. Even though they are not logical and clearly untrue, they render an otherwise thoughtful, kind and caring person seemingly very unwell. However, these illogical thoughts are circumscribed solely to the experience with food and don't take away that person's value as a human being. Even the most confusing parts of an eating disorder cannot take away the humanity and empathy of the person underneath.


"Getting It" Part 2

When people hear about children or young adults developing a serious, potentially chronic and even fatal medical condition, the responses are fairly predictable. Often an adult will feel sadness at the thought of someone early in life struggling, of a life derailed by illness, something most people are fortunate enough to associate with old age. Someone might focus on the unfairness of getting sick young or the loss accompanied with being unwell in the formative years. Many will feel powerful sympathy and even the deep desire to be able to heal a sick child. 

However, these are not the responses to a child or young adult diagnosed with an eating disorder. These reactions are also predictable but much less helpful. An adult often is perplexed at the idea that a child is not eating when food is plentiful. People often get frustrated and angry at the one who is ill. Someone who might sympathize with a sick child instead sees the eating disorder as a personal flaw and consequently only feels sympathy for the parents. 

Unlike other childhood illnesses which elicit support and love, eating disorders lead to confusion and frustration. A child or young adult in pain and suffering with an eating disorder needs care, love and kindness to find a path to recovery. Instead, the child is more often ostracized by the adults most likely to help.

The rise in the incidence of eating disorders was quickly followed by two phenomena that could bind together people with eating disorders against the universal lack of comprehension of these illnesses: the rise of eating disorder treatment programs and the birth and spread of the internet. These two events allowed isolated, scared children and young adults to find others who were sick and understood what they felt and experienced each day. As much as the growth of community has had negative consequences by allowing the birth of the pro-Ana and pro-Mia websites, the connection also created the opportunity to feel understood. 

The concept of "getting it" fundamentally reflects the powerful desire for people with eating disorders to feel understood. From the start, family, friends and clinicians treat them like pariahs, strange, confused and potentially threatening. The power of knowing that someone understands them, their behaviors, emotions and desires, is undeniable. In fact, just the experience of being understood often opens a door to imagining recovery more than any part of treatment. 

When I think back to my first experiences as a therapist in the outpatient program at UCLA, I realize that somehow I really did understand the internal struggle one has with an eating disorder very quickly. There was a level of communication around these illnesses that struck me personally and allowed me to deeply learn and understand. The group caught onto that piece of me and, desperate to feel understood and cared for, capitalized on it during my time in the program. 

In fact, they seemed to indirectly ask me not to abandon them by pursuing other avenues in my career. The message was clear: "Since you get it, we need you to help us. Please understand that not many people can make sense of the struggle and suffering of an eating disorder so use your knowledge to make this your career path. Please don't abandon us."

I got the message loud and clear  and have diligently followed that path. It isn't perhaps until now that I understood the message I received years ago, but I have felt the strong urge to make treating people with eating disorders my calling.

My very late reply to that entreaty from years ago is simple: I will do just that. Thank you.


"Getting It" Part 1

When I first started learning how to treat people with eating disorders, I was a psychiatry resident at UCLA. A colleague and I were the therapists in a weekly group therapy session as part of an intensive outpatient program. The age range of the women in the group was 18 to forties. Calling us the therapists was generous. We learned as much from the patients, if not more, as they did from us. 

I have been thinking about this group lately, more than for some time. In particular, when asked why I treat people with eating disorders, I speak about this group as the initial experience that began a quest to understand and help people with these illnesses. But recently, I have come to wonder whether I actually picked this specialty or, much as people find themselves trapped in an eating disorder, it picked me. 

As an impressionable and nervous resident, participating in this group therapy was a formative professional experience. After a few months, the patients who were more experienced in treatment settings had had sufficient time to vet the new trainees and determine that I, in eating disorder program lingo, "got it."

No stamp of approval was more potent. I had been accepted as a member of the club. I was now deemed worthy as a therapist. I had magically cracked some sort of code of empathy. I understood the complexity and confusion of having an eating disorder. The concept of not eating or of throwing up one's food, in the context of a complex life, made sense. Somehow, I had crossed over and now was one of them. 

I wasn't aware of any of this at the time but instead felt a heady, out-of-body sense that something significant has changed. It felt as if I had something special and had a responsibility to do something with it. 

Interestingly, my new status spread from patients to the clinicians who ran the program. I became one of their chosen residents and, over time, was invited into a small cohort of trainees considered capable of working with people with eating disorders.

The rest of the story is less interesting except that I have devoted my career to treating people with eating disorders. The effect of that initial group was to initiate me into the mindset and confusion of an eating disorder and to teach me how to use my own kindness, empathy and compassion to help a cohort of people left with limited treatment options, even in New York City, perhaps the most therapized city in the world. 

I have since learned hat the concept of "getting it" is central to most programs and patients alike. It has many uses like normalizing the confusion of the disorder, helping someone so alone feel a part of something and serving as shorthand for a therapist to trust. But the term can also signify the recalcitrant nature of the illness and the powerlessness the eating disorder thoughts brutally reinforce. 

In the next post, I will address the concept of "getting it" more carefully. Years after understanding its potent effect on me, I am curious to see more clearly the true meaning of this term.