A recent book by UCSF professor and pediatric endocrinologist Dr. Robert Lustig -- horridly titled Fat Chance -- has turned my mind to past discussions of our program’s dietary recommendations, aka the Kartini Meal Plan.
In its primary and original form the Kartini Meal Plan was developed to refeed children with restrictive eating disorders and weight loss following principles I have spoken about before: real food, cooked at home, eaten together in a spirit of joy. Kartini’s Meal Plan is comprised of about 2150 kcals/ day (adjusted to a patient’s individual needs, of course), of which about 30% comes from fat. It is very, very vegetable-centric, which is what leads some people to claim “it’s a lot of food”. True, when followed as it should be, it is a lot of green vegetables! And some families do alter this part of it, according to their taste and family style (but not at our recommendation).
During the early (hypermetabolic) phase of refeeding, a child/adolescent will likely need far more than 2150 kcals/day to regain lost weight (how exactly we add those calories I have described elsewhere). But what we don’t add is what we call “hyper-palatable” foods (i.e. sugared and sweet). Our reasons for excluding hyper-palatable foods have also been described elsewhere, and are based on my interpretation of clinical evidence from animal studies as well as human starvation studies done during World War II.
But now I’d like to expand the discussion, past the microcosm of Kartini’s meal plan and initial refeeding, to talk a bit about what we at Kartini Clinic are seeing metabolically in our children with AN, BN and binge eating disorder. This is where our meal plan ceases to be simply a refeeding/weight restoration protocol and becomes a broader recipe for "eating for life". If Kartini Clinic were a place that only refed children to a certain weight, did psychotherapy and family therapy for a (short) period of time, and did not follow patients past such an initial phase, we might never have discovered the metabolic issues facing our patients beyond this period of refeeding. We might never have realized that clues to our obesity/metabolic syndrome pandemic are reflected in our patients' experiences as well.
Metabolic Weight Management
There has always been a small number of girls (perhaps 15% - 20%) who, despite apparent weight restoration, do not achieve menarche (first menstruation) or a resumption of regular menstruation. Other medical terms for lack of menstruation include “continued secondary amenorrhea” and “primary amenorrhea”.
And believe me, Kartini Clinic isn’t one of those places that sets weight goals too low in order to achieve “buy-in”. But in the past all we had to offer such children was “more weight gain” -- and it didn’t always work. Such was our dilemma: even when we were able and allowed to push a child’s weight above what they (and even we) were absolutely comfortable with, we weren’t seeing menarche or resumption of menstruation. And since lack of periods can have profound medical consequences - after all, adequate estrogen is critical to cognitive functioning, growth and bones - we were left with a difficult decision. It’s not responsible to let a child linger in an amenorrheic state, as sometimes happens, but it’s also very hard to keep pushing for increased weight gain. Then along came our collaboration with Dr. Emily Cooper and a deeper look at the metabolism of each individual child and teen.
Show Me The Science!
We currently do metabolic testing on all children on admission to our program as part of our effort to understand and work with their individual biology. Typically, in the case of AN and disorders involving weight loss, we see low levels of leptin, low thyroid hormones (TSH, T3, T4), very low female and male sex hormones (LH, FSH, estradiol, testosterone), low zinc levels, low nutritional markers (C3 and total T3) -- all at levels consistent with starvation. And typically, as we track them through weight restoration, these levels come up to normal and the child -- if a girl -- either initiates or resumes menstruation. Boys get their testosterone back and with it their energy. That is, some boys and some girls. Others however, depending no doubt on their genetics, go off the rails in a couple of ways. Some develop insulin resistance and post-prandial hypoglycemia, others develop apparent leptin resistance. Some have stubbornly low leptin levels that act as a “stop!” signal for return of female hormones (no LH surge, low estradiol).
But back to Dr Lustig’s book I mentioned at the outset. I think many people will take away the message of “sugar addiction” and immediately begin restricting the sugar intake of their children (not necessarily their own) or lobbying for schools to do so. This is probably about as successful an approach as other “abstinence” or “prohibition” behavioral approaches have consistently proven to be.
Nevertheless, given that I believe a healthy skepticism about sudden extreme dietary intervention is warranted, what are the useful and important take-away messages of Dr. Lustig’s book?
eat real food -- this admonition, which we at Kartini Clinic have been harping on for more than a decade, is likely to solve most of the problem in one blow. Real food, otherwise known as “ingredients” (!) or “cooking from scratch”, does not come with a food label because it’s not a processed composite. Examples would be: apples and all fruit, fresh vegetables of all kinds, meat, chicken, shrimp, etc. You get the idea.
eat lots of fiber -- fiber is the hero of his story, as sugar (fructose) is the villain, and Dr. Lustig suggests that enough fiber may even counteract the addition of some amounts of fructose (including our daily bread) to our diet. He does not suggest the “fiber” you buy in a plastic container from the store to make you “regular”, though, he is suggesting the fiber found in whole grains and in most vegetables.
Cooking at home -- the majority of the time this is the only way to guarantee the integrity of ingredients.
Sugared drinks of any kind, including juice and sports drinks, are bad for children and may be helping to drive the increase in metabolic syndrome we are experiencing even in those who are not overweight. Dr. Lustig makes the claim that something like 40% of thin people may have metabolic syndrome, which may be worse for your longevity than being fat. In fact, some 20% of fat people who are also fit do not have metabolic syndrome or any other discernable health problems. So fat or thin, the control of sugar (i.e. hyperpalatable foods) may be imperative for all of us in the long run. And yet the problems with doing so are legion, as I am sure you can imagine.
Exercise is good for your health, even very good, but it will not and does not cause sustainable weight loss. I personally do believe this, but “exercise”, as such, is the sword that cuts two ways in a pediatric eating disorder clinic. Aerobic exercise will suppress leptin, something we cannot afford to let happen in cases of continued amenorrhea (see above!), even when our ultimate goal is to return a child to happy activity. The simple fact is that for our children a return to an active life has to be gradual, as it is following any injury. This is not “anti-exercise” advice, in my opinion it is wise counsel.
So there’s a lot to think about, to argue about and to discover, as we help families and ourselves create a meal plan for life.