MedStar Health Blog

Is it possible to perform medical and surgical procedures without transfusion or without using blood products such as whole blood, red cells, white cells, platelets or plasma? Bloodless medicine and surgery—BMS—is a set of strategies and policies that does just that.

As a matter of personal preference or religious beliefs, some patients will not accept a transfusion of blood or blood products. And, in other scenarios, conserving blood and minimizing blood loss during surgery have resulted in safer procedures and faster recoveries. In all these instances, MedStar Washington Hospital Center delivers cutting-edge expertise and the highest level of care to its patients by practicing bloodless medicine.

Our BMS program was established over a decade ago, and our leadership and medical staff have embraced the concept. We’ve adopted new techniques, developed solid policies, and leveraged technology to give our patients safe, effective and clinically sound options for blood products. And our program serves as a model for other healthcare organizations throughout the country.

Transfusion, of course, will always play an important role in healthcare—especially in emergencies and for those living with blood disorders. But substantial data now provides evidence that some transfusions are not only avoidable but could adversely affect patient outcomes.

Decades ago, the idea that major surgery could be performed without delivering blood or blood products to the patient would have been widely met with skepticism. Stored blood was administered in a wide range of situations, often without question. It was simply the routine and, as such, didn’t receive much scientific scrutiny.

But, thanks to some committed, courageous medical pioneers and religious leaders, we can make a very profound statement today:

Virtually no procedure demands the use of blood products, no matter what area of the body is being treated—even organ transplants.

It simply takes good planning.

A Matter of Faith

Certain religious faiths take the Bible’s counsel against use or consumption of blood very seriously. This can be a quandary for patients who want to practice their faith without restriction—yet still receive the best possible surgical care.

The challenge was first recognized when the medical community adopted blood transfusion on a wide scale after it saved lives on the World War II battlefield. But real advances toward bloodless medicine began as surgeons interacted with members of the Jehovah’s Witnesses faith in particular.

Jehovah’s Witnesses have traditionally embraced modern medicine and medical intervention; however, their personal understanding of the Bible does not allow them to accept blood—whether donated or their own—in the course of medical care. In the 1960s, pioneering Texas surgeon Dr. Denton Cooley began performing bloodless open-heart surgeries for the Jehovah’s Witness community. He performed hundreds of such procedures, documenting and publishing results.

Over time, improved approaches and new technologies evolved, and hospitals all over the world began to adopt methods to serve patients who prefer bloodless procedures.

Benefits

Studied for six decades now, bloodless medicine has proven both safe and clinically effective. A few facts:

• Bloodless procedures have a lower mortality rate than those using blood products.
• Patients undergoing bloodless procedures spend less time in the hospital.
• They also experience fewer surgical-site infections.

Overall, these procedures result in better outcomes and lower costs for both patients and the healthcare delivery system.

My father has a favorite saying: “Evolution is better than revolution.” I think of him a lot when discussing BMS. The culture change that it requires can happen very slowly, especially within large organizations. But over time, we’ve seen the dramatic shift as healthcare professionals gain a greater understanding of its benefits.

Essentially a Transplant

Today, we recognize that blood products are tissue, composed of cells and other human biological components. Giving a patient products derived from another person’s blood is, in essence, a transplant. In both training and practice, today’s medical community better appreciates the true implications: even when blood is a perfect match from a reliable and healthy donor, transplantation carries risk.

Medical professionals have always appreciated the gravity and complexity of organ transplantation—and it is typically the last resort, after other interventions fail. For example, we would never consider a kidney transplant as the first course of treatment for reduced kidney function.

In times past, blood did not receive the same deference. But today, the concept of blood as transplant has changed our thinking. Now, we’re more likely to ask: if we have good alternatives, why take the risk?

Safeguarding Blood Cells

The choice of BMS calls for open dialogue between provider and patient, who together review various options to minimize bleeding during treatment, as well as any potential risk.

During medical procedures, each component of blood plays a vital role, but the red blood cells are of greatest concern. Red blood cells bring oxygen from the lungs to all other parts of the body, and their loss can create problematic, temporary anemia and lack of oxygen.

At the Hospital Center, we have a variety of tools and techniques that help reduce the need for transfusion. For example, many of today’s surgical instruments and procedures can minimize blood loss.

Also, two key elements of BMS—cell salvage and hemodilution—aim to safeguard the patient’s blood cells.

• Cell salvage involves gentle suction of blood lost during a procedure. The salvaged material is stored, cleaned and transferred back to the patient as concentrated red cells.
• In hemodilution, a portion of the patient’s blood is collected and preserved before the procedure, and replaced with volume expansion fluid that matches the normal volume of the patient’s bloodstream. In this way, any blood lost during the procedure contains fewer red cells than normal, which means less overall cell loss.

These processes have largely replaced autologous donation—when the patient contributes his or her own blood prior to a procedure. Blood has a very short shelf life; even a few days’ storage can degrade it. So both cell salvage and hemodilution have the added advantage of administering fresher cells to the patient.

Another important element of BMS is anemia screening. Instead of managing a preexisting low blood count with transfused blood during the procedure, patients are carefully screened before the procedure, allowing enough time for treatment. The patient enters the operating room with the healthiest possible blood count, reducing the need for transfusion.

The Role of the Hospital Center

Our BMS program extends beyond the operating room. Behind every procedure and new development are the collaborative and educational resources of the International Training Center for Bloodless Medicine and Surgery, part of the MedStar Health Institute for Quality and Safety.

As we seek to help patients for whom blood conservation is an essential decision, it’s clear that medicine must balance science, art and judgment. The Training Center is both a think tank and a consulting service. It acts as a clearinghouse of research data. We provide classes, many of which grant continuing education credits. We run a hotline for medical professionals with the latest information on BMS.

Only about 90 BMS programs exist nationwide, and there is a great need for more. We help healthcare providers around the country to build and refine their own bloodless programs, putting MedStar Washington Hospital Center and our other hospitals in a leadership role to expand the practice of bloodless medicine and surgery.

I have seen friends and family members face challenges when working with providers who do not embrace BMS programs. I am proud to say that the Hospital Center offers patients the tools and knowledge they need to make an informed decision. And we’re empowered to respect that decision, thanks to bloodless medicine.

If overly large breasts have caused you years of head, neck and back pain, the decision to have medical breast reduction surgery may be one of the most satisfying decisions you’ll ever make.

And if you’ve considered a breast reduction recently, you are definitely not alone. Reconstructive breast reductions for medical purposes in the U.S. numbered well over 60,000 last year, up 6% from the previous year.

Complaints and physical symptoms brought on by overly heavy breasts (known as symptomatic macromastia) can range from strain on the shoulders or neck to deep grooves in the skin caused by the pressure from bra straps. Some patients find they must wear two sports bras in order to exercise, or have difficulty keeping the skin beneath the bra dry and moisture-free, creating rashes and other hygiene problems.

And some studies show that the pressure applied to the neck and shoulders by overly large breasts can also compress nerves that trigger migraines and pain from the front through the rear of the skull and into the neck.

It’s clear that a pound to a pound-and-a-half of extra weight across the chest with no bony support takes its toll on the neck, back and shoulders and can worsen over time.

Breast reduction for medical purposes differs, of course, from cosmetic breast reduction (mastopexy). In mastopexy, we tighten the skin with a lift, which benefits breasts sagging due to extreme weight loss, childbirth or age, where no reduction or augmentation is needed. On the other hand, a reconstructive breast reduction (reduction mammoplasty) involves removing volume and reshaping the breast to help relieve the patient’s physical symptoms. A lift is part of this procedure as well.

Quality of Life

A patient’s quality of life can rapidly become affected by breast hypertrophy—the condition when breasts become enlarged and begin to droop, stretching nerves and spurring neck and back pain.

The patient may be forced to stand and walk differently to compensate for the strain on her muscles and back, potentially affecting her overall posture as well as her self-esteem. Teenagers in particular often struggle with body image if their breasts are extremely out of proportion to their bodies. Hypertrophy can trigger skin irritations, breathing problems, and even skeletal deformities.

When chest size interferes with quality of life, many patients simply want to achieve a physique that’s healthier and less problematic for them.

What Does the Procedure Involve?

In the past several years, I’ve performed approximately 300 of these breast reduction procedures here at MedStar Washington Hospital Center. My patients are generally 20 to 60 years old, although we’ve performed this surgery with great results on females ranging from 18 to 70+ years old.

In reduction mammoplasty, we remove tissue from the breast and create a more optimal contour that suits the patient’s body. Because, in any procedure of this kind, there is the potential for scarring, we operate in such a way that any resulting scars are minimized or not easily visible.

For example, in most breast reductions, we must reposition the nipple, calling for a circular incision around the areola. A cut must be made from the bottom of the areola down to the bottom of the breast, creating what’s known as a lollipop incision. This short-scar method—which reduces the amount and size of visible scars and shortens the patient’s recovery time—works well for thinner, smaller-breasted people with very large breasts.

For other patients, we may perform a Wise pattern lift, which involves an incision along the inframammary fold, in the area where the underwire of the bra sits. The result looks like an inverted T—almost like a traditional boat anchor with a circle, a line down and a semi-circular line across the bottom.

Getting Started

Candidates for medical breast reduction surgery connect with us either directly or by referral from their primary care physician, physical therapist or spine specialist following a long period of chronic back and neck pain.

We review the patient’s breast and mammogram history, pregnancy and breastfeeding history (as well as their expectations to breastfeed in the future), and any family history of cancers. We also examine the patient for lumps, bumps or other breast abnormalities.

Next, we obtain anatomic measurements to help us estimate how much weight or mass to remove in surgery, and to plan the appearance and shape of the breast and the repositioning of the nipple. We review with the patient the procedure we recommend to obtain the best result given her body type and breast structure and mass.

At this stage, we also capture pre-operative photos for the patient’s file, including images of the shoulders, back or any other areas of pain or irritation, to inform insurance coverage of the surgery.

As mentioned, some patients ask if or how their procedure might impact their ability to breastfeed going forward. Over time, we’ve found that some women are able to breastfeed after surgery, while others are not. In the case of a “free nipple graft”—in which we must fully remove the nipple from the breast then reconnect it as a graft—the patient will no longer be able to breastfeed post-surgery. Therefore, we counsel patients that they may want to postpone this surgery until after they have finished nursing for good.

We typically recommend against surgery if the patient has difficulty undergoing elective surgery, if she has a comorbidity such as cardiovascular disease or if she has had an abnormal mammogram or is at risk for breast cancer.

Also, prior to surgery, we ask any patients who are smokers to quit. Smoking and vaping can constrict your blood vessels and affect your skin, which in turn impacts wound healing after breast reduction surgery. Even a small-scar breast reduction requires several inches of incisions, and we want to avoid any barriers to proper healing.

Breast Reductions in Men

Of course, medical breast reductions are not limited to female patients. Surgeries in men have increased about 18% in the last 20 years, from 20,351 in 2000 to over 24,000 per year today.

In men, we tend to see gynecomastia—in which the patient develops abnormally large breasts related to hormonal imbalances, testicular tumors or drug use—or lipomastia, an excess of fat in the chest area. We may perform liposuction to remove the extra fat or, in the case of low-hanging breasts, conduct an actual breast amputation then reconnect the nipples to the chest.

On the Day of Surgery

This is typically a two-hour operation, performed either at MedStar Washington Hospital Center or one of our surgery centers convenient to the patient. Most patients go home the same day.

After check-in on the day of surgery, you will be taken to the pre-operative area, where we start your IV, introduce you to your anesthesiologist and nursing team and begin to mark your chest area in preparation for the operation.

Next, we bring you to the operating area, where the team will place compression devices on your legs to help prevent blood clots, the anesthesiologist will assure that you are set up to breathe comfortably during the procedure and they will administer anesthesia to help you sleep.

When you awaken from your surgery, you will find your chest area protected by a surgical bra—a sort of sports bra with gauze pads. We advise that you continue wearing this bra for support and sponge-bathe until your first follow-up visit.

We generally send our patients home with a small supply of pain medication. Although there is inflammation following this procedure, most patients report feeling very little pain.

Ensuring a Quick Recovery

I see my patients again one week post-surgery, then again at about three weeks, six weeks and three months.

Surgical stitches are removed after the first week, and many of our patients feel well enough to return to office work in a week to 10 days. If you have a position involving a higher degree of physical labor—such as a police officer or a nurse—I typically recommend you take a minimum of two to three weeks off work following your breast reduction. All patients should avoid heavy lifting for three to four weeks after surgery and be gentle with the surgical area for up to six weeks.

For all patients, we predict about six weeks for 90% recovery, and, in most cases, you will be fully healed at three months.

A patient’s likelihood of scarring post-surgery can depend on genetics: Asian Americans and African Americans are more prone to keloids (abnormal scar tissue collection) than are Caucasian Americans. Ten to 14 days post-surgery, I recommend that all patients begin scar and breast massage, using vitamin E oil, cocoa butter or shea butter products, available at most pharmacies. This keeps the skin around the surgical wound soft and helps reduce the chance of very visible scars.

Take Care of Yourself

Remember that it is not necessary to live with persistent pain and discomfort. If you have chronic neck, back or shoulder pain, shoulder grooves from your bra straps or chronic skin irritation beneath and around your breasts, you may well be a candidate for medical breast reduction surgery covered by insurance.

Here at the Hospital Center, outpatient elective surgeries are proceeding as normal despite the current pandemic.

From a patient satisfaction standpoint, breast reduction surgery is easily one of the “happiest” surgeries we perform. Our patients often say, “I felt the difference as soon as I got home” or “I wish I’d done this 10 years sooner.”

Obesity is quickly becoming a worldwide health crisis.

One recent study suggests that it may soon surpass world hunger as a leading catalyst for serious medical conditions globally. In the U.S. today, more than 1 in 3 adults are obese, compared to about 1 in 7 in 1980. The rise in obesity and resulting health problems threatens to reverse the steadily increasing lifespan that Americans have been experiencing in recent decades.   

Although these numbers can be alarming, there is an effective health intervention that can help reverse these trends: bariatric surgery, a procedure to change the size and position of a patient’s stomach and small intestines. Benefits of this minimally invasive surgery can extend well beyond weight loss for obese patients—including near-immediate resolution of several chronic conditions, a reduced need for medications, improved quality of life and increased longevity.

Why It Works, When Diets Fail

Over time, most obese patients have lost weight repeatedly. The pounds can continually return as the body reacts to weight loss by dramatically lowering the patient’s metabolic rate. But this setback doesn’t occur with bariatric surgery.

In fact, with bariatric surgery techniques in use today, we see significant metabolic improvements in our patients, often before any post-surgical weight loss occurs. For instance, there appear to be immediate changes in how the gut signals satiety and hunger to the brain. Other hormonal changes improve how the body metabolizes carbohydrates and fat. Even changes in gut bacteria following bariatric surgery may play a beneficial role.

What’s clear is that bariatric surgery can deliver significant positive health benefits to the body, beyond weight loss alone.

Potential Health Benefits

Here are some common obesity-related conditions that improve with bariatric surgery:

• Type 2 Diabetes: Resolved

Over 80% of obese patients experience complete remission of their type 2 diabetes immediately following bariatric surgery.

That means patients actually leave the hospital with normalized blood glucose and no longer need medication to control it. As a result, they also have a much lower risk of life-threatening damage to the heart and blood vessels from ongoing diabetes. I’ve seen a number of great outcomes for patients here at MedStar Washington Hospital Center.

A five-year research study known as the STAMPEDE trial showed that these dramatic benefits can’t be achieved with diabetes medication alone. When researchers compared obese patients taking intensive medication to control their diabetes with those who also underwent bariatric surgery, only the surgical patients were able to maintain glucose control without medications. They also experienced unmatched improvement in their blood lipid levels and their reported quality of life.

• Hypertension & High Cholesterol: Reduced

Bariatric surgery also offers important cardiovascular health benefits. Between 52% and 92% of obese patients quickly return to healthy blood pressure levels following surgery, depending on how long they’ve had hypertension and how many medications they’ve been taking. Some leave the hospital no longer requiring blood pressure-lowering medicines. Others are able to decrease to a single medication and improve control from there as they lose excess weight.

In addition, patients reduce their overall risk for cardiovascular disease, especially heart attacks and strokes, by 82% following surgery. Some of this is related to the weight loss, and some to metabolic and other changes in the body post-surgery.

For about 63% of obese patients, cholesterol levels return to normal following bariatric surgery as well. (Success rates for resolving this condition are a little lower than for others, primarily because it’s not always weight-related. If your high cholesterol levels are a family trait, you may have a genetic predisposition that bariatric surgery won’t reverse.)

• Obstructive Sleep Apnea: Cured

Nearly 90% of obese patients suffer from this serious sleep disorder, which involves the occasional collapse of throat tissue during sleep, temporarily cutting off breathing. Untreated, sleep apnea increases your risk for a multitude of health problems—from hypertension and heart rhythm irregularities to heart attacks and stroke. While CPAP machines can be a highly effective treatment, they can be inconvenient and difficult to use regularly and reap the full benefit.

With bariatric surgery, 80% to 85% of patients experience complete remission of their sleep apnea in the first few months as they lose weight. Many patients find they no longer need the CPAP machine to maintain normal breathing at night.

• Nonalcoholic Fatty Liver Disease (NAFLD): Resolved

As obesity has increased, so have cases of this chronic liver condition, characterized by too much fat stored in the liver cells. About one in four adults in the U.S. has this form of liver disease today, which is often silent and can lead to inflammation, scarring and even liver failure, similar to damage caused by alcohol abuse.

About 90% of NAFLD cases resolve with bariatric surgery. As a result, we’re seeing more obese patients being referred to us by liver specialists, who recognize the benefits of bariatric surgery for preventing liver failure in these patients.

• Polycystic Ovarian Syndrome (PCOS) Symptoms: Improved

This hormonal imbalance and metabolic problem affects about one in ten women of childbearing age. One risk factor is obesity. Belly fat tends to be very metabolically active, affecting your body’s insulin and producing extra testosterone that can affect the ovaries and trigger the irregular menstrual cycles we see with PCOS.

After bariatric surgery, our patients typically have a 100% resolution of most PCOS symptoms and a 79% resolution of the excessive facial and body hair (hirsutism) that typically comes with it.

• More Benefits

By their two-week follow-up appointment after bariatric surgery, most of my patients have lost 10 to 20 pounds. Besides the immediate health benefits, weight-related headaches, reflux and urinary incontinence go away very quickly as well following surgery.

Quality of life increases dramatically for my patients, as social stigma about their weight goes away and they can more comfortably enjoy travel, work opportunities and physical activities with loved ones.

Within 12 to 18 months, most of my patients have lost 75% of their excess weight and 90 to 95% of bariatric surgery patients maintain that weight loss long-term. This enables a wide range of benefits, from healthier pregnancies, to safer organ transplants and joint replacement surgeries, to the possibility of aging with less disease and dementia.

Perhaps most importantly, statistics show that treated patients typically enjoy more years of life as well, with an 89% lower risk of death within five years of their bariatric surgery. Truly life changing.

How to Begin

In 2013, the American Medical Association categorized obesity as a treatable disease, rather than a lifestyle choice. That announcement, along with the well-documented safety and effectiveness of bariatric surgery, has prompted more health insurers (private and government) to cover the procedure in recent years.

Coverage is still mostly reserved for people whose obesity is severe (a body mass index of 40 or more) or who have a BMI of 35–39 along with a weight-related health condition, like Type 2 diabetes. But it is hoped that bariatric surgery will soon be covered more broadly, as many more people could benefit from it before their health problems become advanced.

If you’re considering surgery, be careful to choose a highly experienced medical center and team. At MedStar Washington Hospital Center, our program is recognized as a Comprehensive Center with the highest level of accreditations from the American Society for Metabolic and Bariatric Surgery. Our connected, multi-disciplinary care team works with you before, during and after your surgery to ensure your care and well-being.

Attend our free online information session, a great way to ask questions and learn more. Then, schedule an appointment to get information about potential insurance coverage and to meet with a bariatric surgeon who can review options with you. Today, most of these visits can be done via telehealth.

Don’t wait to learn more about bariatric surgery. Earlier treatment can bring you a healthier, happier and longer life.

Every 11 seconds, an older adult is treated in the emergency room for a fall, and according to the Centers for Disease Control and Prevention (CDC), every 19 minutes, an older adult dies from a fall.

We can never predict the future, but we can be proactive about the steps to ensure a safe home environment and lifestyle. One of the most common causes of non-fatal injuries and hospital visits for trauma are falls. Fortunately, there are ways to reduce risk and prevent falling.

Falls: myths vs. reality.

According to the National Council on Aging, there are three common myths about falling:

Myth 1: Other people fall, but I won’t.

Reality: One-quarter of seniors fall every year in the U.S. The belief that “it won’t happen to me” is dangerous, because it can happen to anyone. The good news: there are actions you can take to prevent falls. For example, wearing appropriate shoes or keeping throw rugs and other tripping hazards out of your path, are among the ways you can prevent yourself and your older loved ones from falling.

Myth 2: As I age, falling is normal.

Reality: Falling has everything to do with safety precautions and nothing to do with your age. From wearing the proper footwear, to improving strength and balance through exercise, to having your vision checked, all of these actions can reduce your risk of falling.

Myth 3: Taking medication doesn’t increase my risk of falling.

Reality: There are many medications that have side effects that can actually increase the risk for a fall. Some medications make you dizzy or sleepy, which greatly increases your risk of falling. Others may make it difficult to think clearly or make you feel light headed or off balance. It’s important to talk to your doctor about the side effects of the medications you’re taking to understand if they may increase your fall risk.

Preventing fall risks at home.

While accidents happen and falls can occur at any time, there are things you can do around the house to prevent yourself or a loved one from falling. Here are some suggestions of safety measures you can implement throughout the different areas of your home:

Floors

• Use non-slip rugs with rubber backing.
• Wrap up loose wires and cords or tape them down to the floor. Keep them out of walkways.
• Make sure walking pathways are clear of excessive furniture.
• Clear floors of items that can cause someone to trip like shoes, magazines, pets, etc.

Stairs

• Fix loose or uneven steps.
• Install handrails on both sides.
• Attach non-slip rubber tread to steps.
• Increase lighting at the top and bottom of stairs and turn them on when using the stairs.
• Avoid leaving items on the steps.

Bedrooms

• Ensure lamps are easy to reach.
• Use night lights.
• Store flashlights near your bed or where you can easily reach them, in case of a power outage.

Bathrooms

• Add grab bars next to toilets and inside showers.
• Use a non-slip rubber mat or self-adhesive strips on the floor of the tub and shower.
• Add a raised toilet seat to assist with going from sitting to stand or vise versa.
• Use a shower chair or bench to sit on when taking a shower.

Kitchen

• Keep often-used items in easy-to-reach places.
• Never use a chair as a step stool.
• Wipe up spills immediately.

Maintaining a healthy weight can be a constant challenge—and potentially more so in a pandemic situation. Many of us are not as active as we were pre–COVID-19. And when times like these call for us to stay home more, that can mean more snacking throughout the day.

So, as we enter 2021, should we add dieting to our list of New Year’s resolutions? The answer may surprise you. With common-sense food planning, an increase in activity and a positive outlook, there’s no need to depend on a restrictive diet that might just end up making you less healthy anyway.

Magic weight-loss pills or diet plans hyped on TV or the Internet are not real solutions. They’re not FDA-approved or backed by science. They’re mostly designed to help you lose money, not weight.

There is only one real path to weight loss: decrease calorie intake and increase calorie expenditure. In other words, eat less and move more.

Look for Sound Advice

If weight loss is one of your goals, choose your guidance wisely. Speak with a credentialed professional: a dietitian or a doctor who specializes in weight loss and management.

Don’t adopt a plan simply because it worked for someone you know. No single approach is successful for everyone. You may not even need to lose weight—not everyone does. Improper dieting can create significant medical issues for people who have underlying conditions. Dieting for the wrong reasons can lead to disordered eating, depression and other mental health issues.

Be smart. Seek sound professional advice that addresses your health and body type.

Back to Basics

Some key fundamentals apply to every weight loss approach:

• Know your numbers. Weight is a numbers game—understand the optimum number of calories you should consume. Everyone’s number is different, depending on size, gender and activity level. The Internet offers many resources to help, such as MyFitnessPal.
• Consume quality foods, in the right quantity. Favor nutrient-dense foods over energy-dense ones. This means more fruits, vegetables, lean meats and seafood, and less fatty meats and processed snacks, like chips.
• Don’t ignore micronutrients, the vitamins and minerals you get from food. Eating fewer calories without increasing fruit and vegetables can lead to deficiency, and supplementation may be needed.
• Exercise is always a great idea, with so many well-proven benefits, not just for weight loss. You can manage weight without it—but it is much harder. Decreasing caloric intake and increasing activity is the formula that works. It also is great for mental, cardiovascular and overall health, regardless of weight.
• Allow yourself to be human. If you have some sweets or chips, don’t hold it against yourself. The feeling of guilt when we have foods we consider “unhealthy” can lead to cycles of restrictive eating and then binging. Allow yourself to have some treats when you want them.

And to maintain weight loss, keep following these guidelines. Many people who achieve their goal weight think, “I’m done.” It doesn’t work like that. If you return to the way you used to eat, the weight will return as well.

Avoid Fad Diets

By my definition, a “fad” diet presents itself as super-restrictive—no carbohydrates, no beans, and so forth. Some of these diets may work, short-term. But longer-term success can be harder to achieve.

A recent example: the ketogenic (keto) diet. It allows almost no carbohydrates, advocating fat instead, much of it from meat. Keto is a legitimate diet, developed to reduce seizures in epileptic children. But it’s not a healthy way to lose weight.

The level of fat it recommends can cause cardiovascular and digestive problems. And eating fewer than 50 grams of carbs per day for the rest of your life is a lot to ask. Most people can’t stick to it—and as soon as they start eating carbs again, the weight returns quickly.

The key to success is sustainability—a plan you can commit to. For example, if you eat a burger and fries for lunch every day, suddenly trying to adopt a meat-free, raw vegan diet will likely not work for you. A successful diet plan is based around an individual’s habits, tastes and tolerance.

Write It Down

Most people frankly don’t have a very good idea of what they consume each day. As a dietitian, I often hear, “I really don’t eat that much.” But when we probe farther, we usually discover the opposite.

A classic example is salad. To make it more appealing, a patient may pile on croutons, bacon, cheese and fatty dressing. Total up those calories, and that “healthy” salad suddenly has more calories and fat than a plate of nachos.

Side dishes can be problematic as well. So can sugary drinks and condiments. Ketchup is mostly sugar; barbecue sauce is ketchup with more sugar. It all adds up.

Journaling can open your eyes to actual calories consumed and can help you reduce your caloric intake.

You can keep a written journal or track what you eat using an app and website, like MyFitnessPal or SparkPeople. I know it works, both from my own experience and that of my patients. I lost 80 pounds in college, and MyFitnessPal helped a lot.

If you do not have access to apps like MyFitnessPal, writing down what you’re consuming can make you more mindful about what you eat and drink and can help keep you on track for the weight loss you seek.

Plan Ahead, Shop Smart

Effective weight management takes planning. I try to cook enough smart meals on the weekend to last me through the week. If you have to think about menus, shopping and cooking during a busy or tiring day, you’re more likely to quickly grab something that’s potentially unhealthy.

I don’t recommend starving yourself. Eating when hungry is a healthier approach. But planning is key; if you portion out healthy snacks—like fruits and veggies—in advance, you’ll have an easier time avoiding chips and crackers. Skipping meals or “saving” all your calories for one meal is also a bad option as it often leads to overconsumption later and sometimes binge eating.

Plan your grocery shopping, too. Make your list and stick to it. Don’t shop hungry. And shop around the perimeter of the store, where the produce stands and refrigerators are stocked with healthier choices. Avoid the snack aisles. If you don’t buy it, it can’t tempt you.

Healthy choices are often more expensive choices, but there are ways to save. For example, there are services that specialize in food rescue—selling good food that supermarkets don’t want, almost always for purely cosmetic reasons. They can deliver healthy foods right to your door.

And remember, for a weight loss plan to be effective, quantity is as important as quality. If you eat too much, you’ll gain weight. Healthy calories are better than unhealthy calories, but your body doesn’t discriminate. It will convert either to fat. French fries may be vegan, but that doesn’t mean you can eat all you want.

Some Weight Loss Trends

Here’s a little background on some weight loss approaches that attract popular attention:

• Paleo: Paleo is based on what early cave dwellers may have consumed, and can be a healthy choice, depending on how strictly you follow it. It limits beans, dairy and grains but is rich in fruits and vegetables, so you’ll get the micronutrients you need. It’s sustainable, as long as you can do without the foods it doesn’t include.
• Whole30®: This approach calls for 30 days without sugar or sugar substitutes, dairy, beans or alcohol. It can be problematic nutritionally: many people get all their protein from meat when they are following it. As an occasional 30-day reset, it can be a helpful way to train yourself to eat less sugar and consume less alcohol. But repeating Whole30 regularly is probably not the best idea for your health.
• Vegan: A vegan plan can be healthy, especially for people with cardiovascular issues. Vegans need good sources of vitamins D and B12 and protein. With planning, a vegan approach can be low in saturated fat, high in fiber and high in nutrients, and is a great option for anyone who wants to reduce their animal product intake for environmental or animal rights reasons.
• Intermittent fasting: We’re still not sure of the efficacy of this approach. Certain people may lose weight, like talk show host Jimmy Kimmel who says he dropped 70 pounds. But we don’t know for sure if the fasting has a metabolic effect or simply reduces intake. Fasting can be problematic for patients with certain medical conditions, especially diabetes, as well as those prone to disordered eating. And it’s not for people who feel sick or cranky or get headaches when they don’t eat.
• Juice cleanse: If you like green juice, add it to your diet. But consuming it exclusively won’t do you much good, and it won’t rid your body of toxins. Your body has a built-in detox system, your liver, which does an excellent job. Unless you have a medical condition, a juice cleanse won’t hurt you. But any weight loss will mainly come from water weight, and you will regain it quickly when you resume eating.
• Mediterranean: People who live in the Mediterranean tend to live longer than the world average, and their diet is thought to be a major contributor to this longevity. Based on fish, whole grains, fruit, vegetables, oils and nuts, it is balanced and doesn’t cause nutrient deficiencies. It’s a common-sense and healthful approach to eating that’s good for most people, and the approach I recommend most often.

Do What You Can

Staying positive is a daily commitment. Like anything else, if you do it every day, it becomes a habit and gets easier.

Before COVID-19, I worked out every day. That’s more challenging now. It would be easy to get frustrated, focusing on what I cannot do, so I concentrate on what I can. I can’t go to boxing class. But I can run, walk the dog or do yoga in my house.

The same goes for eating—consider what you can do:

• Drink water or seltzer instead of sweet drinks.
• Grab fruit or carrots instead of crackers or chips.
• Choose turkey over beef for your burger, but be sure to check sodium content, as turkey substitutes often have more sodium than their beef counterparts.
• Have egg whites or eggs instead of pancakes.
• Make your own salad dressing; it’s tastier and healthier than the bottled ones. If you like one with zing, try my recipe. It can be kept in the refrigerator for a few days.

Ellie’s Healthy Dressing: Mix ½ cup olive oil, ¼ cup balsamic vinegar, 2–3 teaspoons of Dijon mustard, some pepper, and a VERY small pinch of salt. Add any of your favorite herbs and spices as well.

I’m not a fan of the words diet and lifestyle. I prefer the term mindful, knowing where all your calories and nutrients come from. It takes work to educate yourself about the foods you love and your triggers, and to find healthier choices when necessary.

Healthy eating is mindful eating.