Thursday, June 12, 2008

Don't Super-Size Me: The push for calories on menus

I didn't see the movie Super Size Me, to tell you the truth. The thought of watching someone gorge on super-sized portions just didn't appeal.

IMDb (where I get all of my movie facts) tells us that movie filmmaker Morgan Spurlock embarks on the most perilous journey of his life. He can't eat or drink anything that isn't on McDonald's menu; he must wolf down three squares a day. He must consume everything on the menu at least once and super size his meal if asked.

Just not pretty.

In my two dozen plus years as a therapist, I've shied away from specializing in eating disorders. By not specializing, I do very well in this area, weirdly enough. I won't specialize because frankly, everyone is sensitive about weight (everyone). And weight is very hard to treat, even with "specialist" written before or after your name.

Because it's such a universal, when people tell me that they want to work on their eating I say, "You'll have to find another therapist if that's all you want to work on. I'll work with you on everything else, your behavior, your thoughts, your relationships, your organizational skill, your emotional management, anything almost, except for eating, and certainly not eating disorders. I won't set out to treat those. If they happen to change over our time together, great, but we're not setting out to cure them."

Why? (a) I like success in my work, prefer to see change fast, and (b) These are the hardest disorders to "cure." So put (a) together with (b) and you get my drift. Oh, and did I mention the paradox in all this?*

The truth? Eating really is an emotional affair. How can it not be emotional? It's about how we look and feel; it's so emotional that no matter how you slice it (all puns in this post may be intentional, I'm not sure yet) until you get yourself emotionally grounded, which can take years, it can be very hard, excruciatingly hard to control one's eating.

This is the essence of anorexia, by the way, control. You can't make anybody eat.

And far be it from me to try.

And you can't make anyone lose weight, either.

My patients lose weight, there's no question about it, without focusing on food as a therapeutic issue, perhaps by not focusing on food as an issue. When we spend a year (okay, more) on the emotional stuff, the pounds tend to peel off slowly, but still. It is a lovely thing to see. Two of my patients in the past year have lost over a hundred pounds each. Both had seen me for nearly three years before they started to lose.

No, it's not science, but it does seem to be a pattern in my practice, maybe is for others, too. Get therapy, take it seriously, and you'll get a handle on your life. Eating is a part of life.

I haven't tackled this topic on the blog until now because it's so huge, and I have so much to say about it. The only way is to begin a discussion is to focus on something in particular, and since WSJ offered me the perfect entree, let's start with Page 2, July 10, 2008, The Wall Street Journal, The Push for Calories on Menus.

Apparently some states are passing laws (or trying) to force restaurant chains to list the caloric and nutritional value of items they serve on their menus. Stu Woo tells us that the California and New York state legislatures have joined a movement approved by health advocacy groups such as the Center for Science in the Public Interest. Other advocates for content disclosure include the American Cancer Society and the American Heart Association.

These organizations agree that if we tell consumers what they're eating, they'll be less likely to eat as much.

Menus with caloric and nutritional information might make some foods less tempting, obviously, something restaurateurs are leery about. And they pay taxes, too, which is why state legislatures are keeping their sights low, only targeting large chains with 8 or more restaurants. Advocates believe these measures, posting calories on walls and menus, are a step towards addressing the country's obesity problems.

A May report by the Los Angeles County Department of Health indicates, based upon "conservative assumptions" that posting calories on menus might result in approximately 10% of restaurant patrons ordering reduced-calorie meals. Changing the eating habits of ten percent of anything is amazing.

And it sounds cheaper than years of therapy, so I'm all for it.

Because at the end of the day, weight control is all about calories in, calories out. If you eat more food than you use in a day, the rest goes to the thighs; or wherever your body feels most comfortable storing it.

But wait a minute! Here's another novel idea (not so novel, okay). What about learning the caloric content of food, cooking for yourself, eating from your own kitchen?

I realize it's easier to pick up the Weight Watchers meals (the only diet I ever recommend when pushed to opine). But there's really something very satisfying about seasoning your own food, sauteing those lean meats or vegetables in just a little olive oil, tossing out the egg yokes. Who cares how rich they are in vitamins?

But when I talk like this in therapy, when patients get me to talk weight control, to talk about exercise (they see my bike) and healthy eating (my sandwich), all I get back are blank looks that say, Why would I ever do that?!

Exercise regularly? Cook? Prepare food? Insane!

Which is why I don't treat eating disorders. Although I could steer away conversation about my bicycle, it would be impossible for me to not talk food, not to impose my palate, not to suggest the ideal sandwich. And a patient might think I'm not empathetic to the situation, which is totally not true, patently unfair.

And yet, just a little olive oil and some garlic, throw in a half-inch of fresh ginger, but don't forget to discard it before you eat. . .it's such a good thing. . .

*a paradox works paradoxically, meaning if I say I refuse to work on this with you, you're probably really going to want me to work on this with you.


Clueless said...

Although I've known my therapist for more than twenty years, my eating disorder is the one thing that is the hardest for us to work on. Anytime, he brings it up I become defensive and is such a control issue. When I worked as a behaviorist, I would always tell the staff/parents, "do not get into power struggles." Well, that is a lot of what an eating disorder becomes. I even made sure that I would never meet the criteria for anorexia, but only ED-NOS. It was the one issue that I would never let him in on until I became thin enough that he had to discuss hospitalization. During this past year, I finally started to really talk about it. So, from a patient point of view and a mental health worker point of view, I agree...we are your worst nightmare...maybe, next to borderlines which I happen to also be one.

therapydoc said...

Love ya', Clueless.

MAK said...

From what I've observed on my own, I have to say you are right on target. Now, I'm not a therapist(though I am aiming to be one) but out of my own experience with MY therapist, once we started working over my emotional issues, my drive, my motivation to lose weight increased manifold. I was on Weight Watchers, and yes, I did lose while on it, but then I had a ridiculously busy semester and i dropped it. However, I find that I no longer turn to food for comfort, confronting my issues head on gave me the comfort and the push that I needed.
Oh, yeah, and I'm sorry I never replied to your comment on my blog. Currently, Miami is very hot and humid. I do my best to spend as little time in the heat as possible.

shraddha said...

I can not control my eating!
I need therapy!

therapydoc said...

No problemo, staying out of the sun is really important.

Anonymous said...

Issues around food are so complex. I would definitely say I have "body image issues" though I would not go so far as to say I have an eating disorder.

But just last night I had a dream that I ran 20 miles with a friend and then we stopped at a restaurant. I *wanted* a certain chocolate dessert but I knew it was 1,000 calories. So in the dream I did not order it.

Even though, in the dream, I was telling myself, 'You just ran 20 MILES. You can probably afford to eat a 1,000 calorie dessert.'

But instead, in my dream, I drank water and wanted that chocolate dessert.

The point is that even in my dreams I can't get away from counting calories.

Isn't that crazy?

therapydoc said...

Not so crazy. Crazy might be to eat all that junk after you just ran 20 miles. And we don't really like that word, anyway :)

Midwife with a Knife said...

Hm... on one hand, I think there is something to be said for knowing what's in your food. On the other hand, there is some common sense that should be involved in recognizing that the super double delux cheeseburger with bacon has about a million calories.

And, when I go out to eat, I don't want to be bothered with calories. I just want to be able to eat and enjoy it. I'll have that 1000 cal chocolate because sometimes the sensual pleasure is worth it. I'll worry about calories at home.

All of that aside, it never ceases to amaze me how, when I've been sick, and start eating again (which I usually do before I start exercising) how quickly the weight comes back on until i start exercising. I know there are a couple of phenomena at play here.... a certain amount of that is rehydration, a certain amount of that is from the fasting-feasting phenomenon (fasting lowers your metabolism, your body learns to use as few calories as possible, so when you start to eat again, you put on weight pretty quickly. It's why the very low cal diets tend to be a bad idea..)

therapydoc said...

This always brings up the hot fudge sundae. With nuts? Or without?

Midwife with a Knife said...

Sadly, no nuts. I'm not supposed to eat them. :( And I only cheat on the diet when my gut is working right.

therapydoc said...

See, it's not always the calories, right? After a run, how is a person going to feel eating something rich, for example, as opposed to drinking water, slowly, or juice, or a piece of watermelon, yummmm.

porcini66 said...

Body image is a HUGE topic and a hard one! I have always been...husky. Husky changed to overweight, overweight went to fat, fat went to obese.

One of my challenges has been that, for my whole life, I stuffed all kinds of things in my mouth to "fill the void". That emptiness, that feeling of being different, that horrible aloneness that so many of us face. A lot of what I stuffed in my mouth was candy and junk food...seeking comfort. So, I never fit in typical sizes.

I wore clothes that would cover up my fat. I would try to hide from the fact that it hurt that I was fat and a running refrain in my mind became that "I can't do that, I'm too fat...". Full of shame. For being fat. Mostly though stemming from the fact that I didn't love myself for who I was and was pretty sure that no one else loved me either....

I'm still fat. Always will be, I think. But - and this is a HUGE but - I think of it differently now. And therapy has helped me to get here. I know that inside, I am a good person. I am learning all kinds of things about how I think and what I feel - my emotional development is finally beginning to catch up to my age.

My kids love that I am "squishy". Do I wish that I could be thin and sporty? Yep. Am I willing to do the work? Hmmmmm...tougher question. One issue at a time, for me. Tackled Childhood Sexual Abuse first, then the alcohol abuse....maybe weight will be next in my quest for self realization?

As always, thanks for writing...

Anonymous said...

I think we live in a society where it is almost impossible to not have body images issues. The only way to fight the battle and stay on top of it is to constantly challenge the horrific body images that are being pushed our way by the media. I run body image groups for girls in the 7th and 8th grades, and it is scary to see how every girl in the room thinks she is fat. It is scary to see how much internalized hatred of the body there is. Also- I find denying myself fattening foods makes me feel deprived- which I know means i have a lot of my own food issues to work with. :)

therapydoc said...

I'll bet those kids think you're the best mom alive. You bring up this self-definition thing, how we define ourselves by a mirror, not what's inside of us. Thanks, and sure, who knows what's in store, right?

Isle Dance said...

It was embedded in me early that a scrawny body is an undesirable body - or an intentionally obsessive body - so having an ectomorph body type has brought much ridicule and cruelty. Add in food allergies, and it's a whole bunch of additional fun. That said, if it were not for food allergies, I never would have bothered to learn how to eat healthy. I hope future generations have it much, much easier when it comes to body image. It's such a sad thing to hate what one sees in the mirror.

Jack Steiner said...

Just out of curiosity, how often do you find yourself diagnosing bloggers. I am sure that there must be a few that you have read or are reading that strike a chord.

Or are you able to turn that side off.

therapydoc said...

Maybe I turn it off, but it's more like, I don't care in most cases, with the exception of psychosis which can make a person dangerous. But we're all dangerous.

The diagnosis side of therapy, for me, is a very big So What? People get identified and identify with various disorders, and it's not as if they don't have them, they might, but the treatment ramifications (for me) are already so ingrained that is doesn't matter. I treat everyone with a very selfish motive, what can I learn here from this person, what can this person teach me about him or herself, which is something far more than a checklist in the DSM-IV. When I "get" the person, when I have the relationship, only then would I deign to suggest, Perhaps if you tried. . .

So although diagnosis is important, people are so complicated that it's not important. Diagnosis is easy. Finding what makes 'em sing, now that's hard.

But here on the blog I'm not treating ANYONE. We're all buds, of course, and if anything, you're treating me, see, you're the Pied Pipers. (Thanks for that comment, it really made me happy).

Anonymous said...

I have been part of the fitness community for a good four years, and it is very very easy to obsess over calories. I hate the idea of calories on menus--at least for me, when I go out it is usually for a treat, so I don't care what the calories are. And I'm not eating a gigantic plate of fettuccine usually.

There is this new focus called intuitive eating which really just gets back to the combination of eating because you are hungry and also eating what you like.

I think all of this structure and shaming around food has led us to not even know what our bodies want. Just because we crave a candy bar, does not mean we should eat one--it likely means that you need a fully meal or your blood sugar is low. But I also agree that sometimes eating can be emotionally fulfilling--cooking together and preparing a meal of your favorites can be very long as, with anything, it's not the ONLY enjoyment one gets, and you don't feel guilty afterwards. I agree with you on the not focusing on food part. :)

therapydoc said...

Spiro, this is brilliant. We used to call it demand feeding, the understanding being that a child knows what he or she needs, parents don't, so we overfeed, assume we know. In our zeal for nutrition, parents often over do it.

So kids lose touch with their bodies, and kids become adults, and it gets even harder.

This also explains eating disorders. If we eat what we need we're "good," as they say. And if we like how we feel when we're "good" we don't want to change that by eating again.

We eat to live, so to speak, rather than live to eat (not that we don't love it).

Dr. Deb said...

Supersize movie was a tough watch.

Anonymous said...

Therapydoc…you know you just opened a can of worms with this topic :-)

I absolutely love reading your blogs and I’m glad you touched on this subject.

Through personal experience, I’ve recently decided to go back to school to get licensed in counseling and specialize in eating disorders. After reading your post, it made me question that decision.

Your right doc, the key is taking the focus away from food and onto the underlying issue. It’s not about the food, food is the symptom.

Seeing calories/ nutritional facts only creates more obsessing on the very thing that is consuming (no pun intended) a person with an ED in the first place. Knowing myself, I’ll eat that burger and then feel even guiltier, go home, and eat more. I’m really good at loosing weight, but I’m even better at eating. There’s a lot of shame and guilt with this disease. We all agree that our society is image fixated and we have become weight prejudice.

“I hope future generations have it much, much easier when it comes to body image. It's such a sad thing to hate what one sees in the mirror.”

I too hope as well that this will change for future generations. I believe I went through this personal struggle to help other beautiful girls end that cycle. Therapydoc, you can send patients with eating disorders to me ;-)

Everyone does need therapy.

therapydoc said...

How fabulous is that?! Thanks, Nik

Anonymous said...

I'd recommend seeing the film anyway, by the way, because it's more about the commentary about the food culture as the actual eating of food. In a way, the eating is a way to frame the more general points!

Syd said...

Morbidly obesity really seems to hide the person. It's as if the real person disappears. I'm sure that's the point.

I would like to know your thoughts in a future post on "commitment phobia". Is it real? I have been reading a bit about it and have someone in my life who fits the description. Thanks.

Anonymous said...

I'm counting my blessings. My practice doesn't include nutrition counseling. I actually help children learn to eat, through their mouths. (A small population doesn't come with that ability.)

On the 'exercise' part of my practice, if I am trying to influence someone to learn or change a movement habit - I'm looking for the motivation to do it ("what makes them sing") also. The concept of habit is important - which leads me to comment on the infrequent treat while eating-out. What if the person's habit is to eat out? I see that among many of the people I know - not my clients.

"to talk about exercise (they see my bike) and healthy eating (my sandwich), all I get back are blank looks that say, Why would I ever do that?!"

therapydoc is role-modeling, but the behaviors are so outside of their current lifestyle they cannot imagine these behaviors in themselves.

A couple of posts ago - on ADHD - turning-off the television (or other video screens) was suggested as a part of intervention.

I also think that decreasing video viewing would affect one's lifestyle leading toward healthy eating.

Chew on that one a bit.

Thanks for a great post! - And thanks to all the commenters. Like therapydoc, the rest of us readers benefit from your comments, too.

therapydoc said...

Syd, Commitment phobia is filed under intimacy fear, and there's lots to say. Sure, I'll get to it.

Batya said...

It drives me nuts when people use food as reward/punishment for kids.

therapydoc said...

Right. And yet. Getting the kid to consider that toilet training concept. . .maybe once in awhile an exception?

Jack Steiner said...

On the topic of fitness- I stopped paying attention to calories, fat content etc.

All it did was aggravate me and make eating unpleasant.

Now I eat what I want and I find myself far happier and a few pounds thinner than before. Frankly I expect to see more drop off of me.

And might I add that I wake up every morning and am surprised to see that I don't look like I am 19 anymore.

I still feel young.

therapydoc said...

Jack, that's where it's at, I think, eating on demand is really listening to your body, paying attention to what the whole bod needs, not just what the mouth (brain?) wants. Someone help me here.

Isle Dance said...

Great points.

As a toddler, I felt rushed and overwhelmed by those hard and fast spoonfuls of endless food inserted into the mouth.

By later allowing us to serve ourselves, encouraging us to start small, so as not to waste what we couldn't eat (while reassuring us that we could always come back for more if we were still hungry), we could pause, enjoy and fill up naturally. (One of the most beautiful lessons, ever.)

We had no sugar/processed products in the home during the early years (except for dessert, which was always special and last...and you had to clean your plate first), so that didn't develop as a childhood default food.

And because we had access to healthy food 24/7, I never developed a panic about running out of food. (Unless spending the night where they "closed" the kitchen between/after meals...OMG, the internal horror! But it taught me to rely on/fend for myself and always bring my own. :o)

Stock the home with 90% healthy food. Eat when hungry. Stop when full. There is always more, 24/7.

I will always be grateful for these lesson. Always. And as challenging as my family situation is, I regularly thank them for this - even from afar. :o)

Isle Dance said...

Oh...and like many kids, I rebelled once out on my own. I didn't want to have to prepare food, so I went on a good, long, packaged/fast food stint. I thought it would be an easy solution. Not. That's when food allergies took over and forced me to get back to healthy - and then learn even healthier - ways. Another blessing in disguise because I had to learn the whole food scientific connection. Very, very important.

Anonymous said...

If a patient you are treating for other issues also has an eating disorder or has eating disordered behaviour surely you would address that too? or would you palm them off on another therapist? or work in tandem?

Anonymous said...

Morbidly obesity really seems to hide the person. It's as if the real person disappears. I'm sure that's the point.

if one was moridly obese, and they wanted help with motivition to exercise and take care of themselves what would you tell them?

therapydoc said...

Kiki, if it's life threatening I've always got a team, which includes a psychiatrist, and will refer for assessment for what is called a higher level of care, perhaps a day program or an inpatient stay.

If not, then I'll treat most eating disorders as metaphor, symbolic of most of what is wrong with life for that person. It's never simple and I can never say, really, "This is what I do." You do a lot of stuff in therapy, therapists do some of it, patients do the rest.

Sometimes just sitting in the same room with your therapist feels like the best thing a person does all week.

Baby steps.

Anonymous said...

I'm surprised that no one has mentioned S-E-X. Eating and sex, sex and eating -- the parallels are so....there. Both integrate the body, mind, and heart in complicated ways. Both are a source of unbelievable pleasure, and hold the potential (in our society) for so much guilt, shame, and pain. Both are basic human drives that are rewritten by societal codes. Both are necessary for our good health and the perpetuation of the species, yet both have the potential to kill us.

Therapy is just a band-aid for big social issues that turn healthy human drives into shameful behaviors. Folks end up spending a fortune (in time and money) to *try* to unravel a world that Madison Ave spends a fortune creating. And given what TD has said here about treatment, all that time and money usually doesn't make a dent.

Calories on the menu? How about right next to the price...

therapydoc said...

Nah, much more than a BandAid. I apologize if anyone gets that impression. And surely worth every dime. But maybe it's like food. Some is good, some is healthy, and some isn't.

I love the sex metaphor, of course. Thanks so much for that one. Someone had to say it, friend. Great job.

Anonymous said...

to the person that said morbid obesity hides the person. anorexia hides her too. she starves and starves and starves until there is nothing much left of her. she wants to disappear. i think they are both extremes of the same issue. TD - do you agree?

therapydoc said...

Surely can be. But weight's not that simple. Like I've been kind of saying, if not specifically, it means one thing to one person, another thing entirely different to another person. So sure, anorexia, not eating can be disappearing to one person but reappearing to another.

Anonymous said...

is there a proven link between anorexia and borderline personality disorder?

Anonymous said...

I notice no follow-up to whether reduced TV-viewing would improve eating habits. "all I get back are blank looks that say, Why would I ever do that?!"
rachelz said "The only way to fight the battle and stay on top of it is to constantly challenge the horrific body images that are being pushed our way by the media." TV is a big part of 'the media' and many families habitually watch a great deal of TV.

Frankly, I don't like counting calories either, Jack. But for some people, the details of the process, perhaps combined with the need to control-self, calorie counting may be an effective method.

Just this morning I read something in the newspaper (Monday is diet and exercise day in the Life section) that prompted me to think about this dicussion in terms of dosage. Dosage is implied in the comments around weekly meetings vs. more intense intervention and inclusion of more providers (team).

In the current mindset for dosing physical therapy, er, as little as possible, I'm still dumbfounded with knowing that people receive psychotherapy for years at a time. (I get why that is, no need to go there.) Dosing intervention is very complex, as therapydoc said "not that simple". Some people will work on issues that include weight control on a weekly basis for years. A few might go to a controlled environment for an extended time period in an effort to completely change their behavior and weight. Call it a spa, f-farm - I hate that term, or the media-expanded-definition of "rehab".

In the newspaper there was an article on the reality-TV show the biggest losers - a pitiful confluence of all we have discussed here.

Finally, and my apologies for length, a 'brain' orientation to why people eat may be tied to the ubiquitous use of behavioral techniques in our culture - rewards for certain behaviors. Is it not common, therapydoc, that we internalize behaviors from our parents - like rewarding ourselves for certain behaviors. Food as a reward - has consequences, some not so good.

therapydoc said...

No idea, Kiki. I would guess not. But it's a guess. Depression would be my first hunch. Ask a specialist :)

Anonymous said...

That was a good read, thanks!

I liked "Super size me." There really is a lot more to the movie than just watching him eat :-)

Dr. J

therapydoc said...

I'm thinking I should rent it, thanks.

therapydoc said...

TherExtras, right on about the family of origin eating habits, probably THE most important factor when it comes to obesity.

And about that teev? Isn't here something about the term, couch potato, that just makes a person hungry?

Crabby McSlacker said...

Interesting post--seems like a very smart move not to specialize and particularly not to claim you can "cure" eating disorders.

I think clients are lucky you have a very balanced approach that puts the eating and emotional issues in context.

Scraps said...

I think that TV-watching can increase chances for being overweight; a person sits there, not moving, not interacting, and so many people bring snacks with them to munch while they watch and don't pay a whit of attention to how many calories they're consuming. Sure, some people exercise as they watch, but I suspect they're the minority. And especially for kids, so much of TV time used to be active-play time, running around and burning up energy. (Not to mention, too much TV really messes up kids' attention spans...helloooo, ADD...)

have popcorn will lurk said...

Mint Milanos are my comfort food. *sigh*

My fave paraphrase from Fiddler on the Roof:

I'm not overweight, I'm tall from side-to-side.

  Bring them home, the Homeland Concert There's not much to say. Wait, I take it back. There's SO much to say it is too much. There ...