Pain-Free Living

Underweight and RA

by Bonnie Bruce, DrPH, MPH, RD

Our nation is so focused on the current obesity epidemic, and there is so much emphasis on losing weight, that those of us who are too thin or struggling to gain weight seem at times to be largely forgotten. But being underweight is more common than is usually realized, with about 2% of all Americans fitting into this category.

There’s more than one reason for being thin or underweight. Sometimes, of course, people are thin at least in part because of their genes. If you are thin and can’t seem to gain weight, even when you are trying in earnest, take a look at other members of your family. Whether your parents are just about the right weight, overweight, or thin will play a part in what your own natural body type is. And although you can change your body to a certain degree through diet and exercise, you cannot change your underlying body type. If you were born to be thin, it is unlikely you will ever be big and muscular.

Other possible causes of being underweight include overly restrictive, fad, popular, or medical diets; medical problems that impair the body’s ability to absorb and use nutrients from food; medicines that affect the appetite; not being able to afford, easily obtain, or prepare food; and psychological stress or social circumstances (for example, depression or loneliness) that take away the appetite. In addition, as people age, the senses of taste and smell diminish, making the thought of eating less interesting. Even the changes in eyesight that happen with aging can affect eating. I have worked with older clients who wouldn’t go out to eat because they couldn’t read the menu or who would limit their food purchases because they couldn’t read the food label.

Being underweight can also be the aftermath of some chronic conditions, such as rheumatoid arthritis (RA), and the percentage of people with RA who are underweight may be higher than for the population as a whole. RA may cause the appetite to wane or the sight or smell of food to become unpleasant or nauseating. Tender finger joints may make it difficult or painful even to try to stir a pot of soup or to hold a knife or fork. The depression that sometimes accompanies RA may take away the appetite, and some of the drugs used to treat it may do the same. The end result is that the body is not getting enough fuel for its needs, leading to problems such as fatigue, loss of muscle strength, and reduced ability to fight off infections.

It may seem surprising, but gaining weight can be as challenging or daunting as losing weight. The good news is that lots of people who want to gain weight are able to do so safely, without sacrificing good nutrition. Before you embark on a plan to gain weight, however, you should first make sure that you don’t have any other underlying, undiagnosed medical problems that may affect or be affected by your efforts to gain weight. This is especially important if you have lost weight unintentionally.

Putting on those pounds

To gain weight you have to eat more calories than your body burns up. But how many calories do you need? Don’t just guess. You can use an online calculator such as the one available through ChooseMyPlate.gov‘s SuperTracker to come up with a number. Or if you are seeing a dietitian or know one, ask if he or she could give you a general idea of your calorie needs. Otherwise, here’s a relatively simple and easy way to get a rough estimate of the calories you need to gain weight.

First, multiply your current weight by 10. The number you get won’t take into account individual differences, such as gender, age, and body composition, but it will give you a rough idea of how many calories your body needs to meet its basic everyday energy needs. Second, add about 30% to that number to account for what you burn up in routine physical activity. Again, the number you get won’t take into account individual differences, but it will give you a rough idea of how many calories you need to sustain your current weight.
Lastly, take that second number and increase it by 500. If this new number is realistic for you and you eat that many calories every day, you can expect to gain about a pound a week. Gaining one or two pounds a week is healthy and means that you are gaining weight at a good rate. If this doesn’t sound like much, think about it as gaining 4–8 pounds a month. If 500 calories more a day seems like too much, start small — even by adding only 100 calories a day — and increase as you are able. An extra 100 calories a day over and above what you are now burning up is powerful. It will result in a 10-pound weight gain over the course of a year.

To add the extra calories, you can eat more at standard meal times, eat more frequently throughout the day, or simply eat higher-calorie foods. Most people will take up parts of all these strategies. Whatever strategy you adopt, it is important that your plan for eating fits your lifestyle, needs, and preferences.

It is also important to avoid simply taking in “empty” calories (calories without any nutritional value). Make sure that you eat heart-healthy calories — a special concern for people with RA because they have an increased risk of heart disease. To do this, you need a proper understanding of the sources of all calories — carbohydrate, fat, and protein — and how best to incorporate them into your weight-gain plan.

Carbohydrate. Carbohydrates are the best way to fuel your body, and you need a steady stream of them. Your best choices include whole fruits, vegetables, whole grains, and low-fat or fat-free milk or yogurt. (If you are thinking that whole milk would give you more calories, you are right. But they are not the good kind of calories you want. You’ll find more about this below.) Potatoes, sweet potatoes, winter squash, peas, corn, and lima beans should top your list of vegetables. In normal serving sizes, they pack more calories than most other vegetables. Dried fruits and nectars are higher in calories per serving than most fresh fruits or juices. Other major sources of carbohydrates are cereals and grains. Focus on whole grains. Whole grains are not necessarily higher in calories than processed grains like white rice and pasta, but whole grains are a great source of fiber, nutrients, and antioxidants and have been shown to help reduce the risk of heart disease, cancer, and diabetes.

Protein. You need protein to help support your muscle and organ structure, to maintain your ability to fight infections, and to build compounds that your body needs. The protein foods you choose to eat are important, too. Healthful protein sources include poultry, fish, legumes, lean meats, low-fat or fat-free milk and yogurt, nuts, seeds, and soy foods like tofu.

Fat. Fat also needs to be part of your daily diet — a small amount is essential for the body to function properly. Furthermore, ounce per ounce fat has about twice the calories of protein or carbohydrate, so it can be a good option when you want to sneak in extra calories. But there are two kinds of fat, the good or healthful fats and the bad fats. The healthful kinds are the unsaturated fats and include omega-3 fatty acids. Omega-3’s are found in oily fish such as anchovies, salmon, mackerel, herring, and sardines, which are also higher in calories than other seafood such as shrimp or sole. Nonseafood sources of omega-3’s include walnuts and walnut oil, wheat germ, flaxseeds, flaxseed oil, and tofu. Sources of other kinds of good fats are olives, olive oil, canola oil, avocados, nuts, and seeds — all of which are good ways to get more calories and help keep your cardiovascular system healthy at the same time. An easy way to increase healthy calories from good fats is to top vegetables or breads with olive oil, oil-based sauces, or condiments made from the good kinds of fats, or even to add some avocado, nuts, seeds, or olives.

On the bad or flip side of fat are the saturated fats and trans fats. It is wise to limit your intake of foods that contain large amounts of these fats as they are strongly related to an increased risk of heart disease. Use whole milk, whole-milk cheeses, and butter sparingly because they are high in saturated fat. Red meat, processed lunch meats, hot dogs, and sausage have all been connected with a higher risk of heart disease as well as some cancers. Save these for special occasions in small portions. Fried foods such as French fries, doughnuts, and fried fish or chicken can be sources of trans fats and would definitely not be healthful ways to get extra calories.

Getting started

To get you started, here are a few easy ways, using relatively small portions, to add 100 heart-healthy calories to your day (remember that 100 calories a day can add 10 pounds in a year).

• 15 almonds
• A tablespoon of olive, walnut, or canola oil
• 3 large dried apricot halves, 2 large dried figs,
  1 dried pear, or 1/5 cup of raisins
• A tablespoon of peanut, soy, or almond butter
• 1/4 cup Grape Nuts cereal
• A quarter of an avocado

You may also wish to try liquid nutritional supplements in addition to regular meals. These are easy to consume, and you can carry them most anywhere. However, because foods contain many as yet unknown organic compounds that may confer health benefits, nutritional supplements are better used as true “supplements” than as your main source of calories. You will get much more nutritional bang for your buck by eating food instead of drinking your nutrition. But if you are unable to eat much, liquid supplements are certainly a good option. If you do choose to use a liquid supplement, be sure it is a complete, balanced supplement, not one just meant to “put on muscle.”

Keep track. Just as knowing how many calories you need is important, so is keeping track of how many calories are in the foods you eat. The primary way to do this is by keeping a record or food diary. There are several sites that will let you do this. For instance, try MyFitnessPal.com, where you can create a free account to gain access to a food diary, a mobile app, and a whole community of people watching what they eat. Enter the foods you ate and the program will automatically calculate how many calories were in them. (The site also allows you to see the calorie content of any food, whether or not you add it to the diary.) Alternatively, you can keep track with pen and paper and a calorie count book, which lists the calorie content of many foods. This may seem time-consuming, and at first it will be, but it can help you understand how many calories you typically eat. It will also enable you to gradually learn how to increase the number of calories in your diet.

Eat less, but more often. One strategy that many people find helpful is to eat smaller, more frequent meals and snacks instead of trying to eat fewer, larger ones. This can be a way to make sure you get in all your calories over the day. Sometimes this also means that eating must be made a priority. Hastily put together, on-the-fly eating is often stressful and can result in missing meals or snacks. Eating should be planned. Think one day or, better yet, a few days ahead. Where will you be? Who will you be with? What will you be doing? Make a mental or written note of these points and plan for them. The more detailed your planning is, the less likely you will be to miss a meal or snack.

Plan for difficult days. One of the most difficult problems to deal with when trying to gain weight is lack of appetite. This may be especially tough on days when your RA flares. When this happens, food may become unappealing and you may not feel hungry when you should. On those days, it is especially important to plan out regular times when you are going to eat and stick to your plan, whether you are hungry or not. Keep especially appealing food readily at hand. Find ways to stimulate your appetite or interest in eating. Try adding pizzazz to your meals — make meals colorful and rich in textures that are appealing to you. If it is all right with your doctor, a small glass of wine, beer, or an aperitif may help stimulate your appetite.

Relax. Making your eating experience comfortable and relaxing can also be helpful. For example, you can play soft music while you eat. If you are accustomed to watching the TV news at dinnertime but it’s making you agitated or depressed, switch to something else, or try turning the TV off next time you sit down to eat. A former instructor of mine emphasized the importance of setting a proper, attractive table. It sets the mood, contributes to relaxation (you won’t have to jump up and down from the table every minute to get something), and can even make you feel special — all of which can have a positive effect on your appetite and your desire to eat.

Count bites. If you find eating really challenging — even when you are relaxed — try keeping track of the bites you eat and gradually increase the number of bites at each sitting. It is important to learn to eat more calories at each meal or to spread out the extra calories over the day, but you don’t have to do it all at once. Doing it gradually can be helpful in preventing stomach discomfort and general discouragement. Also, eating more food within the first 20 minutes of a meal is sometimes helpful.

Exercise. Last but not least there is exercise. Although it sounds like a paradox, exercise is very important not only for good health but also for weight gain. Strength-training exercises, including weight-lifting, are good ways to build muscle, put on pounds, and strengthen your body. However, for people with RA, joint pain and stiffness, relative inactivity, and changes in the muscles that lead to loss of strength can make exercise difficult. Still, it is essential to remain active at whatever level you can. Try to do some strength training 2–3 times a week, but don’t overdo it. You should not feel any worse after exercise than you did beforehand. If you haven’t exercised much before, or if you’ve not sure what is right for you, ask your doctor or health-care professional for help. They may also be able to refer you to a physical therapist who can help you create an exercise regimen that fits your needs and abilities and that you can then do by yourself.

If any of these approaches to weight gain sound good, then you are set to go. Remember to take the time to make a plan that you like and that fits you. This way you will be more likely to stick with it. Also, recognize that it will take a while to gain the weight you need. None of us is perfect, and we will most likely not make all the gains we hope or expect. But don’t quit; stay focused. Remember that old saying — a journey of one thousand miles starts with a single step.

Last Reviewed January 10, 2013

Bonnie Bruce is a behavioral scientist and freelance writer based in California.

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