“Why can’t I eat dessert all the time?”

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In our quest to find entertaining and educational television shows for our kindergartner, I stumbled across an animated show on Netflix called “Ask the StoryBots.” In each episode, a child asks a question of the StoryBots, and they try to answer it by traveling to different locations and talking with different “experts” or individuals who might have answers. Most of these questions are about the world we live in, such as “why is the sky blue?” and “how do ears hear?” and they are answered in an accessible way. My daughter and I have found most of the episodes funny, entertaining, and interesting, as the show uses lots of humor and catchy songs to educate its audience. The StoryBots themselves are cute and silly and full of boundless curiosity. And the show also has guest appearances from a number of recognizable celebrities, including Snoop Dogg, Zoe Saldana, and Jason Sudeikis, among others.

When I came across the title for episode 2 in Season 2, I automatically cringed a little bit: “Why Can’t I Eat Dessert All the Time?” Teaching kids, especially little ones, about nutrition can be a tricky thing to do. I remember when our daughter came home from preschool one day and told us that her teacher made her eat lunch in a certain way (i.e., sandwich and veggies first and then dessert), I knew that we would have to step in and explain our food philosophy. The teacher was open to our request to let Lorelai eat her lunch in any order she would like, thankfully. But as the days and weeks went by, we started hearing Lorelai talk about “good/healthy foods” and “bad/unhealthy foods,” phrases we never use in our home, and I knew that it was going to be an uphill battle to maintain her intuitive relationship with food and her body.

Lorelai and I immediately skipped over episode 2 of Season 2 because I was afraid that it would be just another fearmongering treatise on why sugar is bad for us. Later on, I watched the episode by myself, and while I did not find it as harmful as it could have been, it definitely was not ideal.

The StoryBots field a question from a young girl named Lilyn who asks them why she cannot just eat dessert all of the time, as she does not like other food. The StoryBots are stumped and tell Lilyn that they will find the answer to this question and get back to her. The first stop for the StoryBots is at a bakery to ask the baker (played by Christina Applegate) why we can’t eat dessert all of the time. In an attempt to answer the question, the baker rolls out a chalkboard filled with formulaic equations and organic chemistry and begins a very lengthy (and swiftly spoken) explanation, using complicated terms that a child most certainly could not understand. She tells them that “an excess of monosaccharides can have an inherently negative effect on everything from our teeth to our metabolism.” She also explains that given the standardized 2,000-calorie diet, “the ratio of calories to nutrients found within your average sugary sweets deviates significantly from what has come to be widely accepted healthy percentages for what one’s caloric intake should be derived from.” Not surprisingly, the StoryBots are confused and at a loss for words.

Obviously, there is a lot that I don’t love about this explanation, but I especially disliked the part about the standardized 2,000-calorie diet. As we know, the 2,000-calorie standardized diet was created as part of the Nutritional Labeling and Education Act in 1990 as a way of simplifying the nutrition label to make it easier to calculate percentages of daily values. 2,000 calories was settled on after the USDA surveyed men and women and asked them how many calories they ate in a day via self-report. Women reported eating between 1,600-2,200 calories per day while men reported taking in between 2,000-3,000 calories/day. So, using these calorie ranges, researchers decided on 2,000 as it was a “nice round number” that would be easy to use for calculations. That being said, 2,000 calories is an arbitrary amount as we truly do not know how many calories one “should” be eating each day. Some folks need much more and others need much less, and the factors that determine this are largely genetic.

As the StoryBots stare at the baker with utter confusion, Jake the Supreme Cupcake (a cupcake that is a “bad boy”) tells them that they can, in fact, eat dessert all of the time and invites them to join him on a journey. The group ends up at Tummy University, where Jake brings the StoryBots to the Alpha Kobbler Pie fraternity. There the partiers (sweets including cake, Twinkies, and gummy bears) are having a sugar rave and initiating new frat pledges, one of which is a piece of broccoli named Brock. Jake explains that the parties at this fraternity are the best because they are “packed with sugar, which gives you short bursts of energy.” All of the attendees are basically bouncing off the walls and acting “crazy,” which they attribute to being “full of sugar.” Brock finds himself at a ritual initiation called “The Dunk,” where pledges are dunked into chocolate, and he decides to bow out.

At the same time, one of the StoryBots, Bing, gets swept up in the rave and is goaded into chugging a two-liter bottle of soda. Brock warns the StoryBots that drinking a two- liter bottle of soda is bad as “it’s almost 100 times the amount of sugar you find in a carrot!” Terrified, the StoryBots try to stop Bing from drinking the soda, but they arrive too late and find him chugging away. Of course, directly after this, Bing starts acting “crazy” like the others, sliding down the stairs on a sled, doing a cannonball into a glass of soda, etc. The StoryBots look on in horror and ask Brock what they can do. He tells them that they will just have to wait as “sugar gives you lots of energy, but you crash and burn pretty quickly.” Almost immediately, the partiers run out of energy, and all of them have sugar hangovers.

The StoryBots end up leaving with Brock as they do not feel that they got their question answered. Brock also wants to find his place at Tummy University. The group runs into the campus police, who are “healthy fats” including avocado and fish. The police chastise Bing for eating too much sugar and are surprised to see Brock coming out of the rave. The police recommend that Brock speak with Dean Banana who is known to say “every food can make the body a better place.” The police then go on to explain that they are healthy fats that are good for protecting the cells in the body. On the way to finding Dean Banana, the group comes across the “Protein Gym,” where a large sweaty T-Bone steak runs over to the group. He has an Austrian accent (reminiscent of Arnold Schwarzenegger) and tells them that protein is needed for building big muscles, and he challenges them to lift heavy weights. Brock does not feel that this is a good fit for him either.

Next the group comes upon a group of foods (including a bowl of pasta, a loaf of bread, and a potato) lined up at the starting line of a track, getting ready to run a race. Brock tries racing with the group who explain that they are “packed with the good carbohydrates,” which give the body sustainable energy, unlike simple sugar. Brock is unable to keep up with the runners and ends up collapsing at the track and then waking up in a hospital bed at the campus medical center. The doctors are fruits and vegetables and introduce themselves as “vitamins and minerals” that “prevent people from getting sick, make the cells in the body strong, and strengthen the immune system.” The doctors share that Brock’s vitamin and mineral levels are “off the charts,” as he has tons of folate, vitamin C, potassium, and calcium, and they tell him that he would be a great fit at the medical center. Dean Banana shows up and confirms that Brock has found his place among the nutrients. He explains that “while a little bit of sugar tastes good,” it’s protein, healthy fats, complex carbohydrates, and vitamins and minerals that “make people strong, smart, and healthy.” The StoryBots believe that they have finally found the answer to their question and are excited to share it with Lilyn.

Overall, the episode is not completely terrible. It is amusing and interesting and provides some solid nutrition education. What I take issue with though is how the simple carbohydrates are portrayed as “naughty crazy partiers,” while the other nutrients are shows as the “good” ones. Young children have very binary thinking, and setting up this “good food/bad food” dichotomy is not necessarily helpful. The message that children will hear from this is that “good foods” such as protein, healthy fats, complex carbohydrates, and vitamins and minerals are to be put up on a pedestal while simple sugars make you sick. This also gives simple sugars the allure of the forbidden food and can result in children over-valuing these foods rather than just having a neutral place in the diet. Kids are naturally born with the ability to be intuitive eaters, and the more that we intervene and try to push them in the direction of “healthy” foods, away from “bad” foods and scare them about the consequences of eating said “bad” foods, the more likely that they will lose their ability to eat intuitively.

Aside from very general nutrition education, namely telling kids that eating a wide variety of foods will help their bodies grow and feel good, I don’t think that getting into the nitty-gritty of how protein, fat, and carbohydrates function is particularly helpful. In our diet-obsessed culture that demonizes sugar and is responsible for the “childhood obesity epidemic,” these types of messages around nutrition do more harm than good. If you do end up watching this episode with your child, please be sure to explain that sugar is not the enemy and that there is more to food than just the nutrients they contain. Food is about connection, tradition, history and pleasure, not just nutritional content.

Prep

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At the beginning of this month, I had my very first preventive colonoscopy. For those of you in your mid-40s and over, you may know that the procedure is now being recommended at the age of 45 (previously it was age 50) to screen for colon cancer and other bowel issues. So when I turned 45 earlier this year, I booked my colonoscopy for this fall and thought it would be “no big deal.” But as the months went by and the procedure day drew nearer, I found myself getting more and more stressed about it.

I was not feeling anxious about the actual procedure itself because people I had spoken to who had had one told me that it is the easiest part. I was more distressed about the prep for the procedure. I knew that for several days prior, I would need to be on a “low residue” diet (basically low fiber), and then on the day before, I could only have clear liquids (but no red, purple, or blue).

I’ve been eating intuitively for over a decade and have not restricted or changed what I have eaten during that time other than while fasting for blood labs. Even though I knew the low residue diet was important for the procedure, it still filled me with dread, and honestly, I felt quite depressed. I found myself becoming preoccupied with what I “could” or “could not” eat. I obsessively looked at the lists of foods to avoid, and I felt such sadness. Despite the fact that now I was supposed to be eating foods lower in fiber (no seeds, nuts, beans, whole grains, or high fiber fruits and vegetables), it felt reminiscent of my dieting days.

Interestingly, I also found myself eating past the point of fullness more often during this time. It felt like I was having my “last supper” before the prep day, as I knew I would not have solid food for over 24 hours. Even though I rationally knew that food deprivation almost always leads to food preoccupation, I was still surprised at how difficult it felt.

The day of the “prep” was the worst day by far. I had stocked up on Jell-O, tea, apple juice, and vegetable broth, but it was (not surprisingly) completely unsatisfying. On the tip of a friend, I learned that I could also have gummy bears and Jolly Ranchers (just not the red, purple, or blue ones) as they liquify at body temperature, so I had some of those as well. Overall, I was a cranky, hangry person, and all I wanted to do was isolate.

By the time I started drinking the liquid laxative that early evening, I was pretty miserable. I will not go into the details of this part other than to say that I spent a lot of time in the bathroom that night and in the wee hours of the morning.

Luckily, I had booked the colonoscopy for first thing in the morning, which meant that I would be done with it all sooner. And, as advertised, the procedure itself was quick, easy, and painless (I was thankfully asleep for it all.) Of course, I was thrilled to hear that my colonoscopy results were excellent, with no areas of concern, and I will not need to get another one for 10 years.

Once I was able to eat normally again, I quickly noticed that my food preoccupation subsided, and I started feeling more relaxed around food. I was no longer a cranky, hangry mess and was able to eat in tune with my body’s cues.

I am very grateful that my procedure went well. And despite the discomfort, stress, and anxiety I felt during the days prior, I am glad that I had this experience. It reminded me that I never want to go through the restriction/food obsession cycle of dieting again. And it also reminded me that my body is amazing and always trying to protect me – that survival instinct is no joke! My advice to those of you who will be getting a colonoscopy? Take off the day before, make sure you have plenty of supplies at the ready, and remember that this too shall pass.

Thoughts on the New Weight Loss Drugs

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I’ve been meaning to write a blog about the new weight loss drugs for months now, but every time I start, I find myself having trouble with what I want to say, especially since so many of the anti-diet and fat-positive activists I admire have already written such important and insightful pieces on these drugs. For anyone looking for some in-depth research study analysis, I want to point you towards Ragen Chastain, a speaker, writer, and amazing fat activist, in addition to being a certified “statistics nerd” (her words, not mine!). Her Weight and Healthcare Substack is an invaluable resource that takes a hard look at “weight science, weight stigma and what evidence, ethics, and lived experience teach us about best healthcare practices and public health for higher weight people.” Ragen is adept at sifting through the research studies that the drug companies publish to sell the efficacy of these drugs and finding the myriad issues, conflicts of interest, and straight-up bad statistics that these studies exhibit. So please read what she has written on the topic of GLP-1 agonists.

In this piece, I am not going to get into the science behind how GLP-1 agonists such as Ozempic and Wegovy actually work. Instead, I want to talk about how these drugs (and the weight loss drugs that came before them) have become such a lightning rod in the discussion of weight. I was a teenager in the 90s, and I clearly remember when the drug Fenfluramine/Phentermine (Fen-Phen) entered the weight loss scene. There was such a fervor about it on the nightly news, and the marketing by the drug companies was intense. It was touted as a “miracle drug” that could “cure” o*esity, and everyone was going to their doctor to get a prescription. I also remember the news stories that came out. Famously, there was one in the Boston Herald about how Fen-Phen was linked to mitral valve dysfunction, pulmonary hypertension, and other cardiac abnormalities. Subsequently, it was removed from the market due to these risks. It took years before people were convinced that the harms that these medications caused outweighed the “benefits” of weight loss for higher weight people.

There has been a seemingly significant theoretical shift in the medical community over the past few years regarding higher weight (the “o” words”) and weight loss. Unlike previous decades, when people were told that their high weight was their “fault” and was caused by their “unhealthy lifestyle behaviors,” many medical professionals are now putting forth the message that one’s weight is largely out of one’s control (true) and is not necessarily due to “unhealthy lifestyle behaviors” (also true). Most physicians acknowledge that the BMI is a flawed measurement and that there are many factors that play into health other than weight (true again). But instead of pivoting away from using weight as an indicator of health, there has been a push by the medical community to classify o*esity and o*erweight as “chronic health conditions” that must be managed over one’s lifetime. In essence, the medical community is saying that while being fat isn’t your “fault,” it is still a problem and one that needs to be managed.

In our fat-phobic, image-obsessed culture, it makes sense why these new “miracle weight loss drugs” are creating such a stir. Higher weight people are being told, “Hey, we know that your weight is out of your control, but we can help you manage your ‘condition’ with these medications!” In addition, there is a lot of pressure on higher weight people to “get healthy” (even if many of them are healthy by every measure other than weight), and losing weight is still seen as something that will improve people’s health. The marketing that the drug companies have put forth is simply astounding. I feel like I can’t watch a TV show, peruse social media, or even read the New York Times without sponsored content popping up about these drugs. Add to this all of the celebrities and influencers who have been publicizing their weight loss “success,” I would be surprised if any person in a larger body wouldn’t be affected. Currently, I am in a small-mid fat, abled body, and I’d be lying if I said that I hadn’t thought about turning to these drugs. I can only imagine how those who are in much larger bodies than mine and/or in disabled bodies are tempted to try them.

The studies that have been put forth by Novo Nordisk (the drug company who makes Wegovy and Ozempic) have shown that while participants lost about two pounds per month over a 68-week time period (during which they were also dieting and exercising 30 minutes per day, six days per week), at 60 weeks, those who were still taking the medication experienced a plateau in their weight loss, and in a follow-up study the following year, two thirds of the weight they had lost was regained. Conveniently, the studies all concluded at the second year of testing, as we know that the majority of weight regain occurs between two to five years post weight loss attempt. Novo Nordisk also reported that taking their medication leads to positive health outcomes, but a closer look at their studies shows that there were no statistically significant improvements in HBA1C (a measure of diabetes), triglycerides, cholesterol, or inflammation markers.

I don’t blame anyone who feels like they need to try these drugs. For some folks, losing 10-15% of their body weight (the average weight loss reported by researchers) could feel like it makes a huge difference in their quality of life. What I find distressing about these drugs is how hard they are being pushed by the media and medical community despite the long list of side effects and potentially harmful health outcomes that can occur. Wegovy has a Boxed Warning (the FDA’s most serious warning) due to it increasing one’s risk for thyroid cancer, acute pancreatitis, acute gallbladder disease, stomach paralysis, as well as an increase in suicidal ideation, among other risks. But it seems that the medical community feels that losing weight is worth the risk to fat people’s lives. That even though folks report nausea, diarrhea, vomiting, constipation, and stomach pain while on these drugs, it’s okay as it is just the price to pay for one to become “healthy.”

I wish that instead of telling higher weight people that their weight is a problem that can be “solved” by taking these medications, the medical community could instead focus its energy on reducing weight stigma in healthcare, as this (along with weight cycling or yo-yo dieting and healthcare inequalities) has been found to have much more of a profoundly negative effect than weight on one’s health. I wish that we lived in a society that didn’t prize thinness so much. And I wish that everyone could see that weight is just another human characteristic that exists on a continuum and that bodily diversity is a real thing, not something that has to be “managed” or “controlled.”

When Family and Friends Lose Weight

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It’s the beginning of summer, and one theme in particular has been popping up a lot lately in my appointments with patients. It seems like everyone’s mother/uncle/friend from college/cousin has gone on a “weight loss journey” since the winter. As you might expect, witnessing your loved ones and/or friends and acquaintances engage in intentional weight loss can stir up a lot of feelings in those of us who are trying to embrace the bodies that we have. Research on intentional weight loss has found “almost complete relapse” after three to five years. Other data are more specific and suggest 90% to 95% of dieters regain all or most of the weight within five years, while other research has found that between one third and two thirds of people end up heavier than they were at baseline. It can be hard to watch others receive the praise and acceptance that often comes along with these “weight loss journeys.” It’s difficult to watch these folks gain more and more privilege while we remain in bodies that often put us at a disadvantage in our fatphobic society. So what are we supposed to do with all of these feelings?

First off, I try to remind my patients that their mother’s/uncle’s/friend’s/cousin’s bodies are not our business. I firmly believe in body autonomy, or as Ragen Chastain calls it, “The Underpants Rule.” In essence, what someone chooses to do with their body is up to them (as long as it is not harming others). Our family and friends will often make choices that we don’t agree with. And those of us who are trying to fight the near-constant onslaught of fatphobia we are fed on a daily basis feel strongly that these friends/family members are doing harm to themselves and perpetuating diet culture. But at the end of the day, we aren’t in charge of others’ bodies. Just like we wouldn’t want someone telling us how to live in our own bodies, we can’t police others.

That being said, I think there is nothing wrong with protecting oneself and setting boundaries around diet and weight loss talk. If you are active on social media and the friend/family member is an active poster of weight loss updates, befores and afters, or touting their new “healthy lifestyle,” it might be time to either snooze them for a short while or hide them from your timeline indefinitely. This can be done by clicking the “unfollow” button on someone’s Facebook profile or clicking the “mute” button on Instagram. By doing this, you are removing the element of surprise from seeing these things popping up on your timeline. It’s hard to look away or unsee some of these posts, so preventing them from appearing on your social media from the start can be helpful.

Another way that you can set a boundary is by being up front with the friend/family member about how their diet/weight loss talk is affecting you. Sometimes I will help my patients role play what they would like to say to the friend/family member who brings up their diet/weight loss. In these types of situations, I encourage patients to try to give their friend/family member the benefit of the doubt. That is, it is very unlikely that they are intentionally causing you harm or distress; they just are unaware of how this kind of talk can be triggering. Here’s an example of how these conversations can be broached: “Hey, I know that you aren’t intending to, but when you talk about your diet/lifestyle/weight loss journey with me, it makes me feel uncomfortable. I am happy that you are happy with what you are doing, but hearing about it is unhelpful for me as I’m working on accepting my body and letting go of diet culture.” If you are struggling with an eating disorder (and this person knows about it), it could be helpful to also say, “Part of my eating disorder recovery is not engaging in diet/weight loss talk as it can make my symptoms worse.”

If after these tactics, the message is still not getting through, it is within your right to limit your exposure to these individuals. This might mean doing shorter meet-ups rather than long, drawn-out hangouts, limiting your time spent at family gatherings, or getting together less often. If this is not an option, you can take space when you need to at these events, excusing yourself from the room or going for a walk by yourself, for example. I also highly recommend cultivating your own “anti-diet” community either online or in person if you are able to. There are many fat-positive folks all over the world, and it can feel less lonely when you are around those who “get it.” Instagram and Facebook can be helpful in finding these people and connecting with them.

At the end of the day, I hope that the one thing you will remember is that just because your
friend/family member is actively engaging in diet culture, you do not have to go that route. You deserve to embrace and live in the body you have, and you do not have to change it. Your body has never been the problem – our fatphobic culture is.

Being Your Own Advocate at the Doctor’s Office

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Going to the doctor has always been a fraught experience for me. As a child, I was consistently in the highest percentile for weight-for-height, and my pediatrician expressed concern from the get-go. He would talk to my mom about my weight in front of me, and it is probably one of my earliest experiences with the feeling of shame.

As the years went by, my experience with doctors didn’t improve. I would fear going to get check-ups, bracing myself for comments about my weight and how I would need to “do something about it.” Even on the occasions when I would go to the doctor having lost weight, I would be anxious and fearful that my doctor would congratulate me and tell me to “keep doing what you’re doing,” as that meant I would have to continue to restrict, over-exercise, and obsess about my weight.

When my PCP retired about six years ago, I made the conscious decision to try and find a weight-neutral doctor. A fellow non-diet dietitian recommended a concierge doctor as someone who did not push back when she was told that discussions of weight would be off the table. I met with this PCP and explained to her my concerns and my desire to be treated through a weight-neutral lens. While it was clear that she typically practiced from a weight-normative perspective, she said that she understood and would not push back on me regarding weight matters.

Despite having this conversation with her at the outset, I still felt anxiety and dread for my doctor’s appointments going forward. Even though I knew she would not bring up my weight in a negative way or push me to lose weight, the 35+ years of fatphobia I had experienced in the medical space up until then was not so easily erased. After many years of therapy, I’ve come to understand that all of those negative experiences I had with my doctors were traumatic events and that these types of experiences have led to my profound distrust and anxiety regarding physicians.

It wasn’t until about a year ago that I was able to find a doctor who expressly practices Health at Every Size®(HAES), and this has made a huge difference for me. The fact that she truly “gets it” and treats me as a whole person (i.e., not just a number on a scale) has greatly reduced my medical anxiety. I don’t hesitate to reach out to her with my health concerns as I know she will give me sound medical advice that is not tinged with weight stigma. In the event that I need to see a specialist, however, my old fears return, and I have to figure out a way to ensure that I get good medical care.

Many of my patients in larger bodies can relate to my feelings around going to the doctor. Most of them dread going to see doctors because they know that the topic of their weight will inevitably come up. In many cases, these patients have put off getting help for health concerns for fear that they will be weight-shamed. One of my patients struggled with indigestion for months before finally seeing her doctor only to find out she had multiple ulcers. Unfortunately, this experience is not unusual for fat patients. These kinds of instances are often noted as “noncompliance” in medical charts, further promoting the false idea that fat patients are to blame for their health issues when it is really weight stigma at play.

Over the years, I have worked with a number of patients on advocating for themselves in medical settings. In most cases, these strategies are successful, leading to the patient receiving respectful, weight-neutral care. I thought it could be helpful to share these strategies with our readers.

One strategy that has proven to be quite successful for my patients is reaching out to the new provider via email or the patient portal before their initial appointment. I have a template email that I recommend for my patients, but of course it’s best to tailor it to one’s own particular circumstances. In this initial message, I recommend telling the doctor that you are looking for weight-neutral care and providing examples of what that looks like. Some examples are not prescribing weight loss as a health intervention, not weighing the patient unless it is medically necessary (e.g., for proper dosage of certain medications), and not telling the patient the number if they do need to get weighed. In addition, it can be helpful to tell the physician that you have been practicing the concepts of HAES and intuitive eating and that you are happy to provide them with resources if they are interested in learning more.

Sometimes even if you have messaged your physician directly, that message does not get relayed to the rest of the medical staff. This can result in the staff being unaware of your no-weighing preference and lead to an uncomfortable situation at the first appointment. To lessen the chances of this happening, some of my patients have reached out to the medical office manager or the primary care nurse at the doctor’s practice ahead of time to specify that they do not want to be weighed at their appointments. You can also ask them to note it in your chart that you do not want to be weighed so that the staff is aware.

In the event that you are unable to reach the physician or medical office manager before your appointment, many of my patients have found it helpful to bring “Don’t Weigh Me” cards with them to their appointments. These cards were created by Ginny Jones, the founder of more-love.org, an online resource for parents who have kids with eating disorders. Ginny explains that in her own recovery from an eating disorder, getting weighed at the doctor’s office was always a major stressor for her. After investigating whether one needs to be weighed at every doctor’s appointment (hint: you don’t), she found that not being weighed at the doctor’s office greatly reduced her stress when going to these appointments. Ginny created small, wallet-friendly cards that you can use to facilitate the conversation with healthcare providers about not being weighed. Even if you don’t end up giving the card to your doctor, it can be helpful and empowering to look over it while in the waiting room prior to your appointment.

For some patients, even doing the above is not sufficient to allay their fears. In these cases, I recommend bringing a supportive family member or friend to the appointment as an ally. Ideally, this person should be someone who understands HAES and will help you advocate for yourself if you face weight stigma. Even if this person does not end up needing to intervene in any way, just having them next you can be an enormous help. When our bodies are flooded with anxiety, it’s often hard to remember all of the details relayed to us by our physician, so having someone there with you to take notes or ask follow-up questions is a helpful strategy.

Sometimes even doing all of the above does not work, and patients are still subjected to weight stigma at the doctor’s office. In these cases, I remind my patients that they have the right to find a different doctor who will respect their wishes regarding weight-neutral care. Though weight-neutral providers are few and far between, if you can find a fat-positive network in your area, often there will be a referral list of recommended providers (and ones to avoid). For instance, I am a member of the “Boston Area Fatties Meetup” Facebook group (a fat-positive group in Massachusetts), where members can ask for recommendations for fat-friendly doctors and other providers. This group also has an excel spreadsheet of fat-friendly providers in Massachusetts which can be searched by type of provider and location.

Currently, the Association for Size Diversity and Health (ASDAH) is working on compiling a list of fat-friendly providers into a database called the Health at Every Size® Provider Listing Project. According to the ASDAH website, they are working to create a better and more comprehensive listing of healthcare providers who are especially sensitive to the needs of marginalized groups including “Black people, trans people and superfat and larger people.” ASDAH has also provided a timeline of the different phases of this project, and currently (March 2023) they state that they will be launching their “new and improved” listing beta. We will be sure to keep you posted when the HAES Provider Listing is available for use.

Boundary Phrases for the Holidays

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It’s November, so that means that holiday season 2022 is in full swing. The last couple of years, due to the pandemic, we have not been to an in-person family Thanksgiving (the last one being Thanksgiving 2019). While it has been sad to not be able to be in close quarters with our families during the holidays, I also have to admit that at times, I felt relief at not being able to attend in-person Thanksgiving. Inevitably, talk about food/dieting/bodies comes up (especially when we spend Thanksgiving with my side of the family), and it often feels exhausting to try to navigate my way through these discussions. Five years ago, I wrote the Holiday Survival Guide edition of our newsletter, detailing some strategies for dealing with weight/food/diet talk that many of us encounter at these gatherings.

While much of what I wrote in that blog still rings true for me, I have had some more thoughts about how to make these types of holiday gatherings less fraught for my patients. Specifically, I have been thinking about how having your own “boundary phrases” at the ready could be key in helping you get through these tricky situations. And, given that we will be going to an in-person Thanksgiving this year thanks to our daughter finally getting vaccinated and us having boosters, I am sure that I will be putting these into practice for myself.

Boundary phrases are phrases that one can use to establish a boundary with a friend, family member, or acquaintance who has overstepped your comfort level. While boundary phrases can be used in many different situations and for many different reasons, I think having some that are specific to weight/food/diet comments at the ready could help my patients feel more confident at holiday gatherings. As such, I thought it made sense to put together a list of some of my favorite body boundary phrases that have worked for me and for some of my patients. As always, these might not work in every situation, but I’m hopeful that you will see one that feels like a good fit for you.

1. In response to someone making comments on your (or others’) bodies in a negative way.

“Yikes…commenting on other people’s bodies is really not OK!”

“Please don’t comment on my body again.”

2. In response to someone saying fatphobic things to you when they “only care about your health!”

“The only person I discuss my health status with is my doctor.”

“If you truly care about my health, then please also care about my mental health as commenting on my body is harmful.”

3. In response to someone telling a fat joke or making derogatory comments about fat people in general:

“Huh. That’s a really odd thing to say – I’m not sure why you shared it with me.”

“Could you explain to me why that was funny?”

“I hope you aren’t saying this to me because you think I agree.”

4. In response to someone making comments about what you are eating, specifically if they are trying to be “helpful” in identifying “fattening” foods you should avoid.

“Thanks, but I don’t need any diet/nutrition advice. I’m all set!”

“Yeah, I’m not interested in talking about food in those terms. So please don’t do it with me.”

5. In response to someone talking to you about their own diet/ food restrictions for changing their own body size.

“I’m working on making peace with my body currently, so I don’t think I’m the right person with whom to discuss these things.”

“Yeah, that diet sounds pretty difficult and unsatisfying. I’ll pass!”

Again, I know that these phrases might not work exactly for every fatphobic conversation or comment you might encounter at your holiday gatherings, but hopefully, one or two of them could be helpful in setting some clear boundaries with your friends and family members.

Happy Holidays, everyone!

Bee Bo Bumps

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It’s hard to believe it, but our daughter, Lorelai, turned four this month. They weren’t kidding when someone said, “The days are long, but the years go by fast!” Watching this little person grow and learn has been amazing, and I am constantly finding myself looking at her with a mixture of awe and adoration. It is the coolest thing to see how her brain starts to put things together, how she reacts to certain situations, and how she approaches pretty much every experience from a place of innocence and openness.

I was a fan of the author Sandra Boynton growing up, and I knew that I wanted to introduce Lorelai to her work early on. Luckily, I was able to find numerous board books that Boynton has created which have delightful pictures and silly and sweet words to go with them. One of our favorite books is called Belly Button Book! This delightfully colorful book follows a group of hippos that love their belly buttons and are happy to display them in any which way they can. The hippos make sure their belly buttons are front and center during the summer, showing them off at Belly Button Beach and singing the belly button song on warm summer nights. The youngest of the hippos calls the belly button a “Bee Bo!” and repeats this word throughout the book. Obviously, this book has become such a favorite in our house, and we have read it hundreds of times over the past four years.

As a result of reading this book over and over, Jonah and I started referring to our own belly buttons as “bee bos,” and Lorelai picked this up as well. Aside from the obvious adorableness factor, it’s been interesting to see how lovingly Lorelai looks at her own belly button and ours as well. Prior to having a child, I was reluctant to show my belly to others. I don’t remember ever owning a two-piece bathing suit, but I do remember being taught that having a round tummy was not okay. From a very early age, I figured out that flat bellies are better than round bellies, and if you don’t have a flat belly, you better keep it covered. Through my adolescence and much of my early adulthood, I was very self-conscious of my belly and would wear clothes that didn’t accentuate it in any way. To this day, my knee-jerk reaction to someone touching my belly is to flinch initially. But I’ve noticed a shift in my belly thoughts since having Lorelai.

One of Lorelai’s favorite things to do is stick out her stomach as far as she can as she admires her belly. She lovingly strokes it and tells me and/or Jonah to look at it. Of course, we “ooh” and “aah” and tell her how adorable her bee bo is. At some point, she wanted to see what our bee bos looked like as well, so we started showing them to her. At first, I felt some hesitation with doing this as it went against my “no bellies see daylight” mantra, but eventually, I was able to display my belly to her without issue. Lorelai loves touching her belly to our bellies and giving us “bee bo bumps,” and it always makes her giggle with glee.

Just watching her face light up and her absolute delight in her belly has been really eye-opening for me. I don’t ever want her to feel ashamed of her body. I want her to see her body as an amazing part of her. I want her to be able to appreciate the body she has and all that it can do. I also want her to be able to recognize that she is not her body, and that there is so much more to her than just her physical body. I am continuing to work on healing my own relationship with my body, and I really strive to show Lorelai that all bodies are good bodies; ergo, all bee bos are good bee bos. I aim to never speak ill of my body in her presence and to be kinder to myself, especially when I am having a bad body image day. I know that kids learn how to hate their bodies by watching their parents hate their own bodies, and I don’t want that to happen in our house. I just hope she can continue to find the wonder and beauty in her body and that it won’t be taken away from her as she gets older. So to that end I will continue to show my belly when Lorelai asks and to give her as many bee bo bumps as she desires.

My Fat Knee

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About a month ago, I hyperextended my right knee while lying in bed. As a result of this (and a history of knee problems that I’ve had for the past decade or so), I had a very bad flare-up of osteoarthritis. I wish that I could say that I had injured myself doing something much more fun or exciting, but I guess when you are in your 40s, this stuff starts happening to you. Interestingly, aside from the initial sharp pain and chronic aching that ensued for several weeks, I noticed that I had some other feelings as well. The usual feelings of sadness and frustration were present of course, but there was something else too: panic.

When I tried to think about why I might be feeling panic in this situation, I had to wade through a lot of things: history, past trauma, hurt, and fear. Since I have always been in a fat body (although at times it has been straight size through restriction and overexercise), I have had a troubled relationship with medical professionals. Starting from a very young age, I became aware that my larger body was something problematic and to be feared. I have very early memories of feeling ashamed of my body whenever I would be weighed at the pediatrician’s office. I remember my pediatrician warning my mother about my weight percentile on my growth charts, and in turn she would turn her concern into “let’s fix this” mode, keeping an eye on my eating and monitoring my portions. I remember being weighed in my kindergarten class, and everyone’s weights were listed next to their names on the chalkboard, so everyone knew where they “ranked” in body size. I was the heaviest girl, of course.

As I got older, my fraught relationship with medical professionals continued. When I entered my late teens, I switched over from my childhood pediatrician to a family physician who was also a family friend. At one point, I believe he treated at least four of my five nuclear family members. And every year, I would dread going to see him as I knew that my weight would be brought up as an issue.  Of course, there were a few years when I had lost weight that I looked forward to going to the doctor as I knew that I would receive praise and encouragement to keep going (never mind that what I was doing to lose the weight could qualify as an eating disorder). But even occasional weight loss didn’t stop me from feeling anxiety when going to the doctor. Because I knew that my body was still “wrong.”

When I found Health at Every Size (HAES), I felt like I could finally breathe for the first time. At last, here was a paradigm that welcomed my body and encouraged me to take good care of it, no matter what size I was. I stopped my periods of dieting and worked on improving my relationship with food and my body. I found a physician who is weight-inclusive and treats me as a whole entity, not just my weight. I learned how to advocate for myself in medical situations when my weight would be brought up as an issue. I have helped countless patients navigate their own troubled waters of medical weight stigma. I have been in therapy for many years and continue to work on these issues as they arise.

But despite all of this work I have done and continue to do, most medical situations result in that pit-in-my-stomach feeling. I flash back to the decades where I was taught that my ailments or injuries were due to my weight and that feeling of shame and embarrassment that would wash over my face when a doctor would give me the “weight lecture.” All of those years of hearing that my fat body was to blame for almost anything negative occurring to it sunk in deep and etched into my brain. So whenever I have a medical situation, whether it is slightly elevated cholesterol in my lipid panel, a knee injury, or sleep issues, my knee-jerk reaction is to brace for the inevitable “weight lecture.” Never mind that I have found the unicorn of PCPs who not only understands and practices through a HAES lens, but also lives in a larger body herself which makes her even more empathetic. I know that my PCP’s office is a safe space and that my fat body will be treated with care and respect.

And even with all of this knowledge, the past trauma that I have received around my body in medical settings is still present. It makes me sad and also makes me incredibly angry. I think about all of my patients who have been through similar experiences with their healthcare providers. I think about the fact that I hold a lot of privilege (being small-medium fat, white, cis gender, heterosexual, able-bodied, financially stable, etc.) and that those who don’t hold those privileges are treated as less than at best and are downright abused at worst in these medical settings.

It is really enough to make me feel very cynical and jaded about the medical profession as a whole, and as a result, I am hesitant to seek out medical care. But despite this, I know that the only way things are going to change in our medical system is if enough of us stand up and refuse to be treated this way. The more patients that I can help to advocate for themselves in medical settings, the more doctors I can try to educate about the harms of weight stigma, and the more that I can speak up in moments of witnessed weight stigma (along with racism, homophobia, and a plethora of other abuses), the more I feel I can somehow make a difference, even if it is just for one person.

“As long as you’re healthy . . .”

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“Health.” It’s a simple one-syllable word with a deceptively simple definition: “the state of being free from illness or injury.” What I have come to realize over the decade-plus that I have been practicing nutrition therapy as a registered dietitian is that health means many different things to different people. Health is not black or white, but a million shades of gray. But the wellness industry (diet culture’s shapeshifted cousin) would have us believe that health is not only easy to define and simple to identify, but also easy to achieve, if we just try hard enough. Well, sorry, it’s not that simple.

When I was a preteen, I remember feeling like my body was wrong, too big, taking up too much space. My mother and I would go to my pediatrician appointments, where my doctor would hem and haw about my weight. I had always trended on the 95th percentile on growth charts, and every year my pediatrician would comment on it in a concerned way. My mom would echo these concerns at home, gently reminding me that my doctor was worried for my health. When I would cry to my mom about being in a larger body than my peers, she would always come back to this statement: “You are a beautiful girl. We could make some changes to how you eat and exercise. I just want you to be healthy.”

“I just want you to be healthy.” These words ring in my ears as they have been spoken to me in different iterations throughout my life. From concerned college friends after I had gained a significant amount of weight during my freshman year (post diet, of course): “We are just worried about your health.” From my first adult PCP when I was 22 years old: “We just want to make sure you are healthy.” From my mom when I announced that I would be going on a low-carb diet at age 25: “as long as you’re healthy!”

Everyone seemed to say that my health was the most important thing and that being healthy meant being in a “healthy-looking” body. When I actively engaged in dieting, restricting, tracking every morsel, weighing myself multiple times a day, exercising even when I didn’t feel like it or was sick or injured, eschewing lunch outings with friends, losing my period – during these times, everyone marveled at how “healthy” I was. “It’s so nice to see that you are finally taking care of yourself!” my family would crow. “Keep going, get healthy!” my doctor cheered. Little did they know the personal hell I was living in. But at least I “looked” healthy. Or at least my body fit the social norm for what we collectively believe is healthy, i.e., it was no longer considered fat. But inevitably as the weight would come back on, the concerns for my health would resurface.

When I finally gave up on dieting and learned about Health at Every Size® and intuitive eating, I was ready to hear the message. At last, I didn’t need to micromanage my intake and output. I didn’t need to obsessively count and weigh and measure. I didn’t have to give lunch outings with friends a second thought. It was like a freedom I hadn’t felt since I was a child, before I was told that I had a body that was “wrong.” I began to realize that health is not one-size-fits-all and that it looks different for different people. With individuals who have chronic illnesses such as celiac disease or cystic fibrosis or those with physical disabilities such as paralysis or amputation, they would never be able to achieve a state of being “free from illness or injury.” How about the millions of people who deal with depression or anxiety? Are they unable to achieve health as well?

I feel that we need to change our beliefs and expectations around health. In my opinion, health is a multifaceted amorphous concept that is not always attainable. It is also something that changes during our lifespan for a multitude of reasons. Even if we engage in all of the “health-promoting behaviors” we have been told to do, there is no guarantee that we will be healthy. In addition, there is no moral requirement for us to engage in these behaviors. As the wise Ragen Chastain so eloquently states: “Health is not an obligation, a barometer of worthiness, completely within our control, or guaranteed.”

The wellness industry loves to prey on our fears of illness and death. It purports to give us the answers to living longer, healthier lives. All we need to do is buy their program, supplement, or detox, and we can unlock the secret to immortality. It’s a brilliant marketing scheme that swindles millions upon millions of people every year. What if we decided to care more about our mental health and wellbeing? What if we made healthcare accessible to everyone? What if we eradicated weight stigma from the medical field? What if we decided that health doesn’t look the same on every body and that this is okay? My guess is the wellness industry would lose billions of dollars. Worrying about and obsessing over our “health” is most definitely not good for us. I wonder when our society will figure this out.

An Open Letter to Daycares, Preschools, Nursery Schools, and Elementary Schools

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We so appreciate the care you take of our little ones. In fact, I am sure that most parents would agree being able to send our kiddos to daycare, preschool, and/or elementary school is a huge factor in maintaining our sanity. The way that you help our children learn, grow, and adapt is amazing, and we are grateful for you. Having said all this, we need to talk about the policing of our kids’ food in school.

Lately, I have begun hearing more and more from parents whose kids are being sent back home with notes about their packed lunch. One parent received a phone call from a daycare saying that they were not going to give her daughter the 10 M&Ms that she had packed in her daughter’s lunchbox because they were “unhealthy.” Keep in mind, this mom had the forethought to pack in her daughter’s lunch The Feeding Doctor’s lunch box card stating that she did not want the staff to interfere with her daughter’s eating of lunch and that her daughter is allowed to eat any or all (or none) of the foods packed in the lunch in any order she wants. The staff overruled these directions and said that candy is “frowned upon” in their program.

Listen, I get it. In our fatphobic, diet culture world, we’ve been taught that sugar is the enemy. That if we give it to our kids, they will turn into sweets-addicted, hyperactive lunatics who will be out of control, that their bodies will balloon up like Violet Beauregarde in Willy Wonka’s Chocolate Factory, and that their teeth will fall out due to cavities. As a registered dietitian who has a Master of Science in Nutrition and Health Promotion with over a decade of experience in the dietetic field, I’m here to tell you that all of this is false.

Kids are naturally born intuitive eaters. Newborn babies cry when they are hungry and drink breastmilk (or formula) provided by their caregivers until they are satiated. They are perfectly in tune with their bodies’ cues and eat in response to them.  As babies grow and they start eating solids, they continue to eat intuitively. If you’ve ever tried to get a baby to eat anything they don’t want to eat (I’m looking at you, strained peas.), you know they just won’t have it. As kids reach toddlerhood, often their eating habits become erratic. Some days, it seems like my daughter barely eats anything, but on other days, she appears to eat more than a grown adult. Despite this seeming chaos, our kids’ bodies know what they are doing. While meals might seem hit-or-miss during one day, it’s best to look at our kids’ eating over a period of days as things will usually average out.   

Kids usually remain intuitive eaters until the adults in their lives start interfering with their food. Whether it be pressuring kids to take “one more bite” at dinner even if they are no longer hungry, limiting their access to sweets and other highly palatable foods because they are “unhealthy”, or expressing concern about their eating “too much,” parents and other adults can really throw a monkey wrench into their kids’ relationship with food.  Many parents worry about their kids gravitating towards foods that are high in fat, sugar, and/or salt because they themselves have a complicated relationship with those foods. In reality, if we relax around these foods and include them regularly with more “nutrient-dense” foods, we can neutralize them and take the “shine” off of them as well. In my work with kids and families, it’s the kids who are the most restricted around highly palatable foods that end up bingeing on them when they get the chance, sneak eating them in their room, or being hyperfixated on them at their friends’ houses. If we teach our kids that food has no moral value (i.e., eating vegetables doesn’t make you a “good” person and cookies aren’t the devil’s food), they will be able to make choices about what and how much to eat based on their internal hunger and fullness cues.

In addition to being natural-born intuitive eaters, young kids have very binary thinking. That is, when we present them with the idea that there are “good” foods and “bad” foods, they take this information quite literally and are unable to see the gray. So many children feel guilt or shame for enjoying “bad” foods because they feel like they are bad for eating them. This is setting our kids up to have a very charged emotional experience around these foods which can continue on into adulthood for many of them.  If we teach kids that all foods fit and that the most important thing is getting a good variety of all sorts of foods, we can help foster their relationship with food and their bodies.

Another thing to consider is the concept of helping our kids become “competent eaters.” Coined by child feeding therapist and dietitian Ellyn Satter, competent eaters are those who eat in accordance with their hunger and fullness cues while taking into consideration their bodies’ needs and preferences. Parents’ (and caregivers’) role in this process is to be in charge of certain aspects of meals and snacks. Satter’s Division of Responsibility further clarifies that parents are in charge of what food is being served, when and where this food is offered. Meanwhile, kids are responsible for whether they choose to eat the food provided and how much they want to eat of said food. Ideally, parents offer their kids a variety of foods, including both highly palatable foods and foods that are more nutrient dense, and then let their kids eat in accordance with their bodies. This model posits that interfering with kids’ eating by cajoling them to eat more vegetables, discouraging them from eating other foods, or even praising them for eating more nutrient-dense foods will lead to power struggles at the dinner table.

So what can we adults do to help our kids develop a healthy relationship with food and their bodies? Here are some strategies:

  1. Avoid categorizing some foods as “junk” or “bad” and others as “good” or “healthy.” Food is just food and does not have moral value. Food is only “bad” if you are allergic to it or it is rotten or spoiled.
  2. Parents need to provide a wide variety of foods to their kids, including regular access to highly palatable foods in order to take these foods off the pedestal and make them morally equivalent to more nutrient-dense foods.
  3. Caregivers at school should refrain from pressuring kids to eat certain parts of their lunch before letting them eat other parts (e.g., “You need to finish your sandwich before you can have your cookies.”) If a child wants to eat their cookies first, please let them.
  4. Caregivers at school should also avoid confiscating food from kids’ lunchboxes unless those foods are an allergy or choking risk. If the parents packed the lunch, please respect that they know how to feed their kids.  
  5. Finally, school caregivers, please be mindful about sharing your own food anxiety with kids. Kids should not be hearing about your latest diet or how you don’t allow yourself to eat X, Y, or Z. Children are like sponges and absorb all of this information.

Again, thank you for everything you do for our little ones. We are so grateful to have you in our kids’ lives. Let’s help our children develop a healthy relationship with food and their bodies by setting a good example and not letting diet culture into the classroom.