Eating Well

Eating Well for Chronic Conditions

By Kate Lorig, Halsted Holman, M.D., David Sobel, M.D.
Living a Healthy Life with Chronic Conditions

Eating well is important for all people, yet food alone cannot cure disease or make you healthy. Your health also depends on heredity, environment, lifestyle, and the interaction of these factors, as well as the health care you receive. Therefore, instead of worrying about which diet to try, consider how to begin changing specific eating habits. Eating well is more than just eating a variety of foods so your body gets the appropriate amounts of all the nutrients it needs to function properly. It also means maximizing the pleasure and enjoyment of food, while coping with disease symptoms and maintaining a healthy weight.

In this chapter, we discuss some simple ways to begin eating well and enjoy doing it. These include tips for managing a healthy weight, changing eating patterns, and minimizing common problems associated with eating and weight management. Just as with any of the other self-management techniques discussed in this book, learning to eat well can help you feel more in control of your disease.

Managing a Healthy Weight ¹

Achieving and/or maintaining a healthy weight is especially important for people with chronic disease. Your weight can have a considerable impact on your disease symptoms and your ability to exercise or otherwise manage the disease. Therefore, finding a healthy weight and maintaining it are important parts of the self-management process. But what is a healthy weight?

A healthy weight is not an "ideal" weight. There is no such thing as an "ideal" weight for an individual. The tables of "ideal" weights are only general guidelines for weight ranges based on population statistics. These tables should not be used to define your specific weight. Being at a healthy weight does not mean being "skinny" like the popular images portrayed in the media. These body shapes and weights are not realistic for most of us.

A healthy weight is one where you reduce your risk of developing health problems, or further complicating existing ones, and feel better both mentally and physically. Finding a healthy weight depends on several factors, i.e., your age, your activity level, how much of your weight is fat, where the fat is on your body, and whether or not you have weight-related medical problems such as high blood pressure or a family history of such problems. You may already be at a healthy weight and need only to maintain it by eating well and staying active. (Remember, you do not have to be skinny to be healthy. In fact, being too thin sometimes contributes to health problems.) Consult your doctor to help you determine what a healthy weight is for you, given your condition and treatment needs.

The decision to change weight is a very personal one. To help you decide whether or not you are ready, ask yourself the following questions:

Why Change My Weight?

The reasons for losing or gaining weight are different for each individual. The most obvious reason may be your physical health, but there may also be psychological or emotional reasons for wanting to change. Examine for yourself why you want to change.

For example, changing my weight will help me...

Lessen my disease symptoms (e.g., pain, fatigue, shortness of breath, etc.)

Give me more energy to do the things I want to do

Feel better about myself

Change the way others perceive me

Feel more in control of my disease and/or my life

If you have other reasons, jot them down here:

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What Will I Have to Change?

Two ingredients for successful weight management are developing an active lifestyle and making changes in your eating patterns. Let's look closely at what each of these involves.

Physical activity burns calories and regulates appetite and metabolism, both important for losing weight. Physical activity can also help you develop more strength and stamina, as well as move and breathe more easily. In other words, activity doesn't wear you down or out, but actually boosts your energy level.

Making changes in your eating patterns does not mean following a rigid, starvation diet, but starts by making small, gradual changes in what you eat. This may mean changing the emphasis or quantity of certain foods you eat. You can begin by reducing the fat and increasing the fiber in your diet. A high fiber, low fat diet helps weight management; it also can help reduce cholesterol and prevent constipation.

Some hints for reducing fat and increasing fiber:

Eat more poultry and fish, less red meat

Choose leaner cuts of red meat

Trim off the outside fat and remove the skin from poultry

Moderate use of organ meats (liver, kidneys, brains) and egg yolks

Broil, barbecue or roast meats instead of frying them

Skim fat off stews and soups

Use low or nonfat milk/milk products

Use butter, margarine and oils sparingly in cooking

Eat a variety of fruits and vegetables, raw or slightly cooked

Eat low fat grain products (e.g., whole wheat breads, brown rice, cereals, etc.)

Snack on fruit or nonfat yogurt, not cookies or ice cream

Drink plenty of water to help move the fiber through

While most of us are concerned with losing weight and keeping it off, some people with chronic disease struggle to gain or maintain a healthy weight. If you experience a continual or extreme weight loss because your disease or treatment interferes with your appetite and/or depletes your body of valuable nutrients (such as protein, vitamins and minerals), you may need to work at gaining weight. To do this, find ways to increase calories and proteins you eat. Unfortunately, these may also add fat to your diet. Check with your doctor or dietitian to see which of the following tips are appropriate for you.

Tips to help maintain or increase caloric and nutrient levels:

Eat smaller meals frequently during the day

Snack on calorie-rich foods such as nuts, seeds and dried fruits (not "junk" food)

Drink high calorie beverages such as shakes and malts

Eat high protein foods

Use milk to prepare creamed dishes with meat, fish or poultry

Add meat to salads, soups and casseroles

Add milk or milk powder to sauces, gravies, cereals, soups and casseroles

Use melted cheese on vegetables and other dishes

Add butter, margarine, oils and cream to dishes

Don't skip meals

If your doctor or dietitian feels they would help, use protein, vitamin and mineral supplements

You can find more information on healthy eating in the references listed at the end of this chapter. Particularly useful is the USDA's Eating Right the Dietary Guidelines Way .

Am I Ready to Change for Good?

If you have decided that you want to change, next consider if you are ready to make these changes for good. Remember, success is important. If you are not ready, you may be setting yourself up for failure and those nasty weight "ups and downs." This is not only discouraging but unhealthy. Therefore, try to plan ahead. Is there someone or something that will make it easier for you to change? Or, are there problems or obstacles that will keep you from becoming more active or changing the way you eat? Will worries or concerns about family, friends, work or other commitments affect your ability to carry out your plans successfully?

Things That Will Enable Me to Make the Desired Changes:

Example: I have the support of family and friends.

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Things That Will Make it Difficult for Me to Change:

Example: The holidays are coming up and, there are too many gatherings to prepare for.

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Looking ahead at these factors can help you find ways to build support for desired changes, as well as minimize possible problems you may encounter along the way. Use the chart above to help you identify some of these factors.

After you have examined these things you may find that now is not the right time to start anything. If it is not, set a date in the future for a time when you will re-evaluate these changes again. In the meantime, accept that this is the right decision for you at this time, and focus your attention on other goals.

If you decide that now is the right time, start by changing those things that feel most comfortable to you. You don't have to do it all right away. Remember, slow and steady wins the race.

To help get started, keep track of what you are currently doing. For example, write down your daily routine to identify where you might be able to add some exercise. Or keep a food diary for a week to see what, when, why and how much you eat. This can help you identify how and where to change your diet. The sample food diary may be useful. Next, choose only one or two things to change first. Allow yourself time to get used to these and then add more changes.

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Common Obstacles to Weight Management and Eating Well

Whether your goal is weight management or just eating for good nutrition, changing old eating habits is no easy task. In this section, we will discuss common problems associated with making these changes, as well as some strategies for dealing with them.

Problems with Losing Weight

"Gosh I wish I could lose ten pounds in the next two weeks. I want to look good for...."

Sound familiar? Most everyone who has tried to lose weight wants to lose it quickly. This is a hard pattern to break because, although it may be possible to lose 5 or 10 pounds in one or two weeks, it is not healthy nor is it likely to stay off. Rapid weight loss is usually water loss, which can be dangerous, causing the body to become dehydrated. When this happens you may also experience other symptoms such as light-headedness, headaches, fatigue and poor sleep. Rather than doing this to yourself, try a different approach -- one employing realistic goal setting and positive self-talk.

For example:

Set your goal to lose weight gradually, just one or two pounds a week.

Identify the specific steps you will take to lose this weight (e.g. increasing activities and/or changing parts of your diet).

Change your self-talk from "I really need to lose 10 pounds right away" to "Losing this weight gradually will help me keep it off for good."

Be patient. You didn't gain weight overnight, so you can't expect to lose it overnight.

"I can lose the first several pounds relatively painlessly, but I just can't seem to lose those last few pounds."

This can be frustrating and puzzling, especially when you have been eating well and staying active. However, it is quite common and usually means that your body has adapted to your new calorie intake and activity level. While your first impulse may be to cut your calorie intake even further, it probably won't help and could be unhealthy. Remember, you want to make changes you can live with. So, ask yourself how much of a difference one, two or even five pounds will really make. If you are feeling good, chances are you don't need to lose more weight. It is not unhealthy to live with a few extra pounds, if you are staying active and eating low-fat foods. You may already be at a healthy weight given your body size and shape. Remember that you may be replacing fat with muscle, which weighs more. However, if you decide that these pounds must go, try the following:

Modify your goal so you maintain your weight for a few weeks, try to lose a pound every two weeks instead of every week.

Try adding to your exercise goals, especially if the current exercise you do has become easy. Exercise will help you to use more calories and maintain your muscle mass. Less weight will be stored in the form of fat.

Again, be patient and allow your body time to adjust to your new patterns.

"I always feel so deprived of the foods I love when I try to lose weight."

The key to reaching and maintaining a healthy weight is to make changes you can tolerate, even enjoy. This means they must suit your lifestyle and needs. Unfortunately, when thinking about losing weight, most of us tend to think of all the things we can't eat. Change this way of thinking now! There are probably as many (if not more) enjoyable foods you CAN eat than ones you should limit. Sometimes it is just a matter of learning to prepare foods differently, rather than eliminating them completely. If you like to cook, this is your opportunity to become creative, learning new recipes or finding ways to change old ones. There are many good cookbooks on the market today to help you make this process more enjoyable. Some of these tips were outlined in this chapter, and more can be found in the references listed at the end of the chapter.

"I eat too fast or I finish eating before everyone and find myself reaching for seconds."

Eating too fast happens for a couple of reasons. One may be that you are limiting yourself to only two or three meals a day, not eating or drinking between meals. This can leave you so hungry at mealtime that you practically inhale your food. Another reason may be that you have not had a chance to slow down and relax before eating. If you find you are too hungry, feeling stressed out, or in a hurry, try one or more of the following:

Try not to skip meals. In this way you are less likely to overeat at the next meal.

Allow yourself to snack on healthy foods between meals. In fact, plan your snacks for mid-morning and afternoon. Keep a banana, some raw vegetables or a few crackers with you for those "snack attacks."

Eat more frequent, smaller meals. This may also be easier on your digestive system, which won't be overwhelmed by a large meal eaten in a hurry.

Chew your food well. Food is an enjoyable necessity! Chewing your food well also eases the burden on your digestive system.

Drink plenty of water! Six to eight glasses of water per day is recommended. This helps you to eat less, and helps prevent medication side effects, aids elimination and keeps the kidneys functioning properly.

Try a relaxation method about a half an hour before you eat.

"I snack while I watch TV (or read)."

If you know this is a problem for you, plan ahead by preparing healthier snacks. For example, rather than eating "junk" food like chips and cookies, munch on fresh fruit, raw vegetables, or air-popped popcorn. Try designating specific areas at home and work as "eating areas" and limit your eating to those areas.

"I enjoy eating out (or I hate to cook), so how do I know if I'm eating well."

Whether it's because you don't have time, you hate to cook, or you just don't have the energy to go grocery shopping and prepare meals, eating out may suit your needs. This is not necessarily bad if you know which choices are healthy ones.

Some helpful tips:

Select restaurants offering variety and flexibility in types of food and methods of preparation.

Plan what type of food you will eat and how much. (Bring the leftovers home in a doggy bag.)

Choose items low in fat, sodium and sugar or ask if they can be prepared that way. For example, appetizers might include steamed seafood or raw vegetables without fancy sauces or dips, or bread without butter. For an entree, you might try broiled, baked or grilled meat, fish or poultry. Avoid breaded, fried, sauteed or creamy dishes. Instead of a whole dinner, consider ordering a la carte. For dessert, select fruit, non-fat yogurt or sherbet. You might split a dessert with someone else.

Order first so you aren't tempted to change your order after hearing what others have selected.

"I eat when I'm bored/depressed/feeling lonely, etc."

Many people find comfort in food. Some people eat when they don't have anything else to do or just to fill in time. Some eat when they're feeling down or bothered. Unfortunately, at these times, you often lose track of what and how much you eat. These are also the times when celery sticks, apples or popcorn never seem to do the trick. Instead, you start out with a full bag of potato chips and, by the end of an hour, have only crumbs left. To help control these urges, try to:

Keep a food-mood diary. List what, how much and when you eat. Note how you are feeling when you have the urge to eat.

Make a plan for when these situations arise. If you catch yourself feeling bored, go for a short walk, work on a jigsaw puzzle, or otherwise occupy your mind and hands.

"Healthy food doesn't taste the same as real food. When I eat, I want something with substance, like meat and potatoes! The healthy stuff just doesn't fill me up!"

Just because you are trying to make healthier food choices does not mean that you will never again eat meat and potatoes. It only means that you will change some of the ways you prepare these foods, as well as what you buy at the store. Some of these tips were already discussed. Additional information is available in the references at the end of this chapter.

"But I LOVE to cook!"

If you love to cook, you are in luck. This is your opportunity to take a new cooking class or to buy a new recipe book on healthy cooking. Again, experiment with different ways to modify your favorite recipes, making them lower in fat, sugar and sodium.

"I'm living alone now, and I'm not used to cooking for one. I find myself over-eating so food isn't wasted."

This can be a problem, especially if you are not used to measuring ingredients. You may be overeating or eating a "second dinner" to fill time. Or maybe you are one of those people who will eat for as long as the food is in front of you. Whatever the reason, here are some ways to help you to deal with the extra food:

Don't put the serving dishes on the table. Take as much as you feel you can comfortably eat and bring only your plate to the table.

As soon as you've finished eating, wrap up what you haven't eaten and put it in the refrigerator or freezer. This way, you have leftovers for the next day or whenever you don't want to cook.

Invite friends over for dinner once in a while, so you can share food and each other's company.

Problems with Gaining Weight

"Food doesn't taste as good as before."

If you have had a tracheostomy, are receiving oxygen through a nasal cannula or are taking certain medications, you may have noticed a decrease in your taste sensations. To compensate, you may have also noticed that you've been increasing the amount of salt you add to your foods. Be careful of this because a high sodium intake can cause water retention or "bloating," which can result in increased blood pressure. To avoid this, try enhancing the flavors of foods by:

Experimenting with herbs, spices and other seasonings. Start with just about 1/4 of a teaspoon in a dish for four people.

Modifying recipes to include a wide variety of ingredients to make the food look and taste more appealing.

Chew your food well. This will allow the food to remain in your mouth longer and provide more stimulation to your taste buds.

If the decline in taste is keeping you from getting essential nutrients, you may need to adjust the caloric content of these foods. Tips for doing this are listed in this chapter.

"It takes so long to prepare meals. By the time I'm done, I'm too tired to eat."

If this is a problem for you, then it's time to develop a plan, because you need to eat to maintain your energy level. Here are some hints to help:

Plan your meals for the week.

Then go to the grocery store and buy everything you will need.

Break your food preparation into steps, resting in between.

Cook enough for two, three or even more servings, especially if it's something you really like.

Freeze the extra portions in single serving sizes. On the days when you are really tired, thaw and reheat one of these precooked, frozen meals.

Ask for help, especially for those big meals or at family gatherings.

"Sometimes eating causes discomfort." Or, "I'm afraid I'll become short of breath while I'm eating."

People who experience shortness of breath may find it difficult and physically uncomfortable to eat meals, so they tend to eat less and are often underweight. For some, eating a large meal causes indigestion. Indigestion, along with a full stomach, reduces the space your breathing muscles have to expand and contract. This can aggravate breathing problems. If this is a problem for you:

Try eating four to six smaller meals a day, rather than the usual three larger meals. This reduces the amount of oxygen you need to chew and digest each meal.

Avoid "gas producing" foods or those that make you feel bloated. You can determine which foods affect you this way by trying different foods and observing the results. Often these foods include vegetables such as cabbage, broccoli, brussels sprouts, varieties of onions, beans, and fruits like raw apples, melons, and avocados, especially if eaten in large quantities.

Eat slowly, taking small bites and chewing your food well. You should also pause occasionally during a meal. Eating quickly to avoid an episode of shortness of breath can actually bring one on. Slowing down and breathing evenly reduces the amount of air you swallow while eating.

Practice a relaxation exercise about half an hour before mealtime, or take time out for a few deep breaths during the meal.

"I can't eat much in one sitting."

There is no real need to eat only three meals a day. In fact, for many it is recommended that you eat four to six smaller meals. If you choose to do this, include "no fuss," high calorie snacks like milk, bread and fruits or liquid protein shakes as part of these extra meals. If you still can't finish a whole meal, be sure to eat the portion of your meal that is highest in calories first. Save the vegetables, fruits, and beverages for last.

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Problems with Maintaining Your Weight

"I've been on a LOT of diets before and lost a lot of weight. But I've always gained it back, and then some. It's so frustrating, and I just don't understand WHY this happens!!!"

Many of you have probably experienced this problem, which occurs because the diet was short-term and calorie-restricted; it did not emphasize changes in eating habits. This type of diet involves drastic changes that cannot be tolerated for long. Because your body does not know when more food will be available again, it reacts physiologically to this deprivation, slowing its metabolism to adapt to a smaller amount of food energy. Then, when you've had enough of the diet, or have lost the weight and return to your old eating habits, you gain the weight back. Sometimes you even gain back more weight than you lost. Again, the body is responding physiologically, replenishing its stores, usually in the form of fat. This fat serves as a concentrated energy source to be called upon again when calories are restricted. This causes the weight to go up and down in cycles which, as mentioned before, is unhealthy and depressing.

This situation is further complicated by feelings of deprivation, as you probably had to give up favorite foods. Therefore, when you reach your goal weight, you begin to eat all of those foods again freely and most likely in larger quantities.

The key to maintaining a healthy weight is developing healthy eating habits that are enjoyable to you and fit into your lifestyle. We have already discussed many of these tips earlier in this chapter. A few additional tips include:

Setting a small weight range as a goal, instead of a specific weight, that you consider to be healthy for you. Weights fluctuate naturally. By setting a range, you will allow yourself some flexibility.

Monitoring your activity level. Once you have lost some weight, exercise 3 to 5 times a week to improve your chances of keeping the weight off. If possible, gradually increase your activity level.

"I do okay maintaining my weight for a short time. Then something happens beyond my control, and my concerns about what I eat become insignificant. Before I know it I've slipped back into my old eating habits."

If you had only a little slip, don't worry about it. Just continue as if nothing happened. If the slip is longer, try to evaluate why. Is there a situation or circumstance requiring a lot of attention now? If so, weight management may be taking a back seat for a while. This is okay. The sooner you realize this the better, and try to set a date when you will start your weight management program again. You may even want to join a support group and stay with it for at least four to six months. If so, look for one that:

Emphasizes good nutrition and the use of a wide variety of foods.

Emphasizes changes in eating habits and patterns.

Gives support in the form of ongoing meetings or long term follow-up.

Eating well does not mean that you are forever forbidden to eat certain foods. It means learning to eat a variety of foods in the right quantities to maintain your health and/or better manage your disease symptoms. This involves changing your eating patterns and emphasizing foods that are lower in fat, sugar and sodium. These changes are important for effective weight management. If you choose to make some of the changes suggested in this chapter, remember that you should not feel like you are punishing yourself, nor that this is a life sentence to boring, bland food. As a self-manager, it's up to you to find the changes that are best for you. And if you experience setbacks, identify the problems and work at resolving them. Remember, if you really want to, you can do it!

Community Resource Detective's Kit

Nutrition Information

U.S. Department of Agriculture,
Room 325-A,
6505 Belcrest Rd.,
Hyattsville, MD 20782

Public Library
Local Health Library
Public Health Department
Agricultural Extension Service
Local American Heart Association
Local American Dietetic Association
Local American Cancer Society
Local Health Center or Clinic

Suggested Further Reading

American Heart Association . An Active Partnership for the Health of Your Heart. Dallas: American Heart Association, 1990.

Brody, Jane. Jane Brody's Nutrition Book . New York: Bantam, 1982

Deutsch, Ronald M. and Judi S. Morrill, Ph. D. Realities of Nutrition , Revised Edition. Palo Alto, CA: Bull Publishing, 1993.

Escott-Stump, Sylvia. Nutrition and Diagnosis-Related Care . Philadelphia, PA: Lea and Febiger, 1988.

Peters, James A., Burke, Kenneth, and Debra White. "Nutrition and the pulmonary patient," in Pulmonary Rehabilitation. Guidelines to Success . Hodgkin, John E., Zorn, Eileen G., and Gerilynn L. Conners, Eds. Stoneham, MA: Butterworth Publishers, 1984.

Williams, Sue R.S "Drug-nutrient interactions," in Essentials of Nutrition and Diet Therapy . St. Louis, MO: Times Mirror/Mosby College Publishing, 1990.

United States Department of Agriculture . Eating Right the Dietary Guidelines Way . U.S. Department of Agriculture, Human Nutrition Information Service. Hyattsville, MD., 1990.

Vegetarian Eating

Lappe, Frances. Diet for a Small Planet . New York: Ballantine, 1985.

Robertson, Laurel, Carol Flinders, and Bronwen Godfrey. Laurel's Kitchen: A Handbook for Vegetarian Cookery and Nutrition . New York: Bantam, 1978.

Weight Control

Breitrose, P. The Weight Kit . Stanford Center for Research in Disease Prevention, The Health Promotion Resource Center, Stanford University, 1990.

Ferguson, James M. Habits Not Diets , 2nd ed. Palo Alto, CA: Bull Publishing, 1988.

Nash, Joyce D, Maximize Your Body Potential , Palo Alto, CA: Bull Publishing, 1986.

Waltz, Julie . Food Habit Management: A Comprehensive Guide to Dietary Change . Ed. Fay Ainsworth and Susan Sommerman. Edmonds, WA: Northwest Learning Associates, 1982.

Notes

1. Portions of this chapter have been adapted from two publications: Thinking About Losing Weight? Northern California Regional Health Education Center, Kaiser Permanente Medical Care Program, 1990. The Weight Kit. Stanford Center for Research in Disease Prevention, Health Promotion Resource Center, Stanford University, 1990.

Copyright * 1994 Bull Publishing Company. From Living a Healthy Life with Chronic Conditions, by arrangement with Bull Publishing.