Healthy Eating and the Gift of Imperfection

By Robin Eickhoff, MD, MPH

My entire life, I have battled

weight. My mother says she named me after a bird because I always had my mouth open for food. It makes me smile, because I know there is truth to it. I love food. I love thinking about it, reading about it, cooking it and definitely eating it. The downside is the false perception that I must decide between being overweight and enjoying my life the way I want, because there is no middle ground. This is the battle many fight every day: “It’s all or nothing.”

As with most things in life, when we try to be perfect and inevitably fail, we quit. Healthy eating and nutrition is not an all-or-nothing proposition. We must give our patients and ourselves the gift of imperfection.

The topic of healthy eating can fit in two buckets: metabolic (nutrition) and behavior (dietary). The two buckets are on each end of a continuum with a myriad of conditions that may (or may not) be influenced by intervention. I will address each and how pathology can influence them, including information on eating disorders. I will then offer suggestions for interventions in an office setting that I believe improves patient outcomes.

Nutrition, the metabolic bucket, requires the balance of macronutrients and micronutrients to maintain and manage good health. Macronutrients are carbohydrates, proteins and fats. Micronutrients generally refer to vitamins and minerals, which come with a balanced diet. Media influence has led many to believe that carbohydrates are bad, proteins are good and with fats, it depends. In reality, we need all three for normal metabolic function, or disease ensues. Chronic diseases, particularly in more advanced stages, can result in deficiencies and inadequate nutrition. Sometimes, however, it is the treatment of those diseases that can cause the malnutrition. Medications can cause weight loss and malnutrition (chemotherapy) or weight gain and over-nutrition (antipsychotics, insulin). When malnutrition is due to a disease state, it is rarely desired, so patients strive to correct the deficiencies to the best of their abilities. When a patient is suffering from malnutrition, I am more inclined to tell them to eat whatever they prefer until their nutrition has improved. Success depends on the cause. End-stage diseases are more likely to result in the catabolic state of cachexia, which rarely improves.

Intended weight loss resulting in malnutrition is more commonly caused by an eating disorder, making it much harder to treat. DSM 5 defines eating disorders as mental health disorders, “characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning.”

These fall more into the behavior or dietary bucket, but can cross over into the metabolic bucket affecting nutritional status when not responsive to treatment. The most common eating disorders seen in a primary care setting are anorexia nervosa, bulimia nervosa and binge-eating disorder. These disorders tend to have higher prevalence in post-industrialized, higher-income countries. Risk of developing anorexia or bulimia tends to be more likely in cultures that appear to value thinness. As one would expect, higher risk exists in occupations such as modeling or elite athletics that focus on being thin as healthy. Going into specifics about each of these eating disorders is well worth its own article and will hopefully be addressed in a future edition.

Most patients we encounter do not have an eating disorder, but instead struggle with being overweight or obese. This often comes with a sense of shame and personal failure. We want to help patients overcome these barriers by empowering them with knowledge and tools about nutrition and healthy eating. How do we do this? There are recommended nutritional guidelines, but each person must be individualized. There are numerous eating plans, but no one-size-fits-all plan. No matter what the recommendation, it needs to be sustainable.

The science of nutrition changes based on new data and studies. The benefits of quality, whole, natural food do not. We need carbohydrates, but ice cream and broccoli are not created equal. Fats are necessary for living, but unsaturated fats are best. Complete proteins are required. The daily American diet typically contains more protein than neces-

sary, but protein can be obtained from many surprising sources. For example, mushrooms have the same amount of protein per gram as carbohydrates. Recently, the USDA released updated Dietary Guidelines for Americans and overall, recommendations appear to be reasonable. Guidelines focus on the intake of nutrient-rich, high-value foods and minimal amounts of sugar and processed foods, while acknowledging the need for customization and moderation. Up to 15% of daily calories may include saturated fats and/or sugar-rich foods and beverages. This allowance is more likely to result in long-term success for changes in diet and improved nutrition.

I have tried just about every diet out there. I have tried Green Smoothie diet, Weight Watchers®, pre-made meal plans like Jenny Craig®, Atkins®, South Beach® and my last and most successful diet: counting daily macronutrients. This worked for me because I had choices, and maybe more importantly, an accountability coach that I reported to weekly with my successes and challenges. I was never shamed or made to feel inadequate, only asked possible reasons for why I made a poor choice and how to prevent it from happening again. In other words, I was given permission to be less than perfect. My best effort was enough.

If we want to ensure success in our patients, we need to provide them with accountability. That can be difficult when working in a busy clinic, managing schedules and keeping up on documentation and billing. Accountability can take many forms, however. It can be weekly weights and measurements with an MA, or even just a phone call from staff obtaining home readings and reviewing the weekly successes and challenges. Patients, just like us, want to be successful. Information is important, but as I am finding in my own life, accountability is what motivates me to change. Once progress is seen, motivation often becomes internal. Being accountable and supportive, however, can be the pivotal factors to push success. Over time, less external accountability is needed, because personal accountability develops. How we provide that accountability will be up to us and our patients.

A healthy diet includes balance between the metabolic component (nutritional) and the behavioral component (dietary). Each of these, when not in harmony, adversely affects the other. Poor dietary choices can cause undesirable nutritional outcomes that can cause disease or influence existing disease. Disease, whether chronic or acute, physical or mental, can adversely affect metabolic state and require dietary changes to minimize poor outcomes. Considering this when advising and treating patients, along with placing an emphasis on personal preferences, moderation of less nutritional foods and providing supportive accountability, can help patients be successful. Most importantly, when helping patients with an eating plan that will result in permanent change, give them permission to be less than perfect. It is important to do the same for yourself in the changes you want to make in your own life, dietary or otherwise. After all, we are all human.

Robin Eickhoff, MD, MPH is a Family Medicine physician with WellMed and is a member of the Bexar County Medical Society. (For more detailed resources on Dietary Guidelines for Americans, including infographics, visit: dietaryguidelines.gov/resources)