“Good Shot”

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“Learn to say ‘good shot,'” my physical therapist suggested as I prepared to return to competitive tennis last fall. Her advice had nothing to do with sportsmanship. Rather, it was a half-sarcastic quip that reflected her assumption that I would not be able to reach balls that I was capable of tracking down years ago and a note of caution that it might be in the best interests of my back to not even try for them if I had any doubt.

She had a point, but only to an extent. Charging forward towards a drop shot, watching the ball fall for its impending second bounce, inching the butt of the racquet handle further towards my finger tips to take advantage of whatever length I can muster, I often think to myself, “Why aren’t I there yet?” Sometimes I forget I am a 40-year-old with a bunch of titanium in my spine. Then reality hits: The ball – just out of my reach – takes its subsequent plop on the court, my physical therapist’s advice echoes in my mind, and I glance up at my opponent and offer, “Good shot.”

While my back does not directly limit my game, it has an indirect impact. Managing my back means exercising intuitively, paying attention to the feedback my body gives me, and doing my best to balance physical activity with rest. Not being able to practice and exercise as much as I once did means that my fitness level has taken a hit and my game is not quite as crisp, which consequently has affected my level of play. My second serve, for example, which used to be as consistent as the sunrise, sometimes lets me down now and I just have to accept that. The upside, however, is that my back feels so good that I never worry that I am endangering myself by trying for every ball.

Both of my tennis leagues began in October and recently concluded. My overall record between the two was an even .500, a far cry from the three-year winning streak I had from 2003 to 2006, but I have always figured that if someone more or less wins as many matches as he loses, then he is playing at the competitive level where he belongs.

My level of play was at least good enough for me to rejoin the Amherst-based team that I played for when I lived in western Massachusetts during my nutrition studies. Sports are about more than exercise and competition; they are social experiences and opportunities to hold on to an aspect of playfulness that can sometimes get lost with age. When the season wrapped up, I emailed my teammates, namechecked the guys who remained from my first stint with the club over a decade ago, and told them, “You have no idea how much I missed being part of this team.”

Returning to the team marked a milestone of sorts for me, which reminded me that we just passed the one-year anniversary of another moment of personal significance: my first time back on the court since my operations.

Tennis has always meant a lot to me, but I never quite realized just how much until I went through the prolonged period of not playing, the uncertainty of whether I ever would again, and then ultimately my return. See, the thing is, walks can be interesting, swimming is okay, lifting weights is cool sometimes, bike rides can be fun, and running is great – but tennis, that’s what I love.

January 7, 2017

He Said, She Said: Menu Calorie Counts

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He Said

Nutrition information has its upsides, but the data are only as useful as their interpretation. Context and framework matter; without a solid foundation, food labels and menu calorie counts can do more harm than good.

Maslow’s hierarchy of needs suggests that we, as humans, have basic needs that must be met before we can fulfill more advanced needs. Nutrition has a similar structure. At the base, someone has to have food – period. If food security is an issue, whether it is due to financial limitations, self-imposed restriction, or any other factors, then not much else matters. At the structure’s very top rests the hard science of nutrition as it relates to whatever medical conditions we may have; this is where we might talk about grams, calories, or various micronutrients. In between are issues of eating behavior that often go overlooked and yet are critical to address. Many people want to jump right to the top, but the danger in doing so is that without a solid middle, the structure is likely to fall apart.

Nutrition labels on packaged food can be helpful to someone with a healthy relationship with food and their body, but in the hands of an individual who does not have the solid middle that I previously discussed, the information can be misinterpreted, maybe reinforce a good/bad food dichotomy, and lead to or exacerbate issues like weight cycling and disordered eating.

In grocery stores, at least, we have a certain level of privacy and ambiguity that may mitigate the damage. Few shoppers probably recognize the yogurt in your cart as being higher in calories than its counterparts, and ultimately neither your fellow shoppers nor the cashier know whether that ice cream you are buying is for your kid’s birthday party or for yourself. Such uncertainties can help comfort people who fear judgment from the people around them.

Calorie counts on restaurant menus present a more complex problem. We place our orders in front of friends, family, co-workers, acquaintances, waitstaff, and fellow patrons who are primed for judgment because they – thanks to the menu – know how many calories you have elected to order for yourself.

Certainly, not everyone judges, and some of us are coated with more Teflon than others, but for many people, even the mere fear that the person across the table may be thinking “No wonder you are so fat/skinny/slow/etc.” can be enough to cause problems. The middle layer of the nutrition hierarchy involves making food decisions based on internal cues rather than external constructs. Issues of guilt, virtue, judgment, praise, and fear cloud the picture and make the establishment of this kind of relationship with food that much more difficult to attain.

Of course, restaurant nutrition information can be helpful sometimes – for example, I remember looking at the Bertucci’s website with a patient of mine in search of menu items that would mesh with his sodium restriction – but it can be provided in ways that are cognizant of potential harm. My suggestion: Post nutrition information online, as many chain restaurants already do, and have it available on site per customer request, but leave it off the menus.

 

She Said

When Jonah and I went to Bertucci’s Italian Restaurant the other night, we both realized that the menu had been redesigned (Clearly, we are regulars at Bertucci’s!). In addition to new entrees and different graphics, I was dismayed to see calorie counts prominently displayed above each and every menu item. I remember when the law was passed requiring all chain restaurants to publish their calorie information on their menus, but for some reason I had forgotten about it. (I feel like the law was passed a few years ago and just now is being implemented.) In any case, it was jarring for me to see this information, and it also made me quite concerned for my patients with eating disorders (ED).

Most, if not all, of my clients with EDs have engaged in some sort of calorie counting. Whether tallying up carbs, “macros,” or points, these patients have misused the nutrition information available to them in order to help them engage in ED behaviors. Much of my work with these individuals is around helping them to move away from the counting because it is completely antithetical to intuitive eating.

As Jonah and I have discussed before, intuitive eating is the practice of using one’s internal cues rather than depending on external factors to make food decisions. That means that someone who is an intuitive eater will (most of the time) eat when they are physically hungry and eat what they are hungry for in an amount that is satisfying. It’s about trusting your body to tell you what it needs and then honoring your body’s needs by fulfilling them.

Most of my patients with ED struggle with the idea of intuitive eating because it flies in the face of what their ED is telling them – food is to be carefully monitored and planned, certain foods are bad for you and should be off-limits, you can’t trust your hunger cues, etc. Many of these patients use calorie counting as a way to gain some control, to feel like they know exactly what they are putting in their bodies. One of my patients who is doing quite well in her ED treatment says that she still can’t shake the calorie counting habit, and she notices that this behavior ramps up when she is anxious, stressed, or overly hungry. One could say that calorie counting is a coping mechanism for many people because it helps to alleviate unpleasant feelings by giving them something concrete to focus on.

In any case, I often encourage my patients to ignore nutrition labels as it can trigger their ED. And in many cases, it is possible to (mostly) avoid this information – by purchasing unpackaged foods, buying prepared food from smaller restaurants or stores, etc. However, with this legislation, many more people will be exposed to calorie information at restaurants that they have gone to for years, and it is inescapable. I know that much of the nutrition information for chain restaurants has been available online for years and that anyone could just look up the calories on the restaurant’s website, but that at least takes a bit of effort. If someone really does not want to see this information, they will avoid it, but printing it directly on the menu makes that nearly impossible (short of never visiting the particular restaurant again).

In my opinion, I think that calorie information should be made available if the customer requests it. Everyone has the right to know what they are putting into their body. But it would be great if restaurants could also provide menus without the calorie information in order to prevent triggering individuals with ED or a history of disordered eating. It could make a number of people feel safer in these establishments, and that would make a big difference in many people’s lives.

Politics

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Shortly after we published our March e-newsletter, I received an automated notification informing me that one of our readers had unsubscribed. His given reason: “your political bias – no thanks.”

The only overt political statement we made is that we had followed through on our promise to donate all of the co-pays we collected between Thanksgiving and New Year’s to the Southern Poverty Law Center (SPLC), an organization that fights hate, teaches tolerance, and seeks justice. Huh, I wonder which of those missions our reader objects to the most?

Anyway, at first I felt bad, as if the loss of a reader indicated a shortcoming on my part. Maybe I had crossed a line of some sort by bringing politics into our work.

On the other hand, fuck that. Acknowledging that nutrition is political and declaring what we stand for is important for our practice’s identity.

Nutrition is science, and science, as recent times have reminded us, is political. A couple of weeks ago, I participated in the Boston March for Science. Take a moment to steep in the ridiculousness that is having to stage a protest in hopes that our current leaders will incorporate evidence into their proposed policies.

Nutrition is healthcare, and healthcare, as Republican efforts to destroy Obamacare have reminded us, is political. Today, the House voted for the American Health Care Act, which – if enacted – will result in the loss of health insurance for millions of people and hasten death for many of our fellow citizens. The American Medical Association has condemned the Act, while I remember would-be patients who were unable to receive treatment because their insurance refused to pay. I think to myself: This is only going to get worse.

Nutrition is cultural, and our culture, as we have known for years, is political. Regardless of her intentions, Michelle Obama’s support for the “war on obesity” made our societal focus on weight that much more glaring. Our current, umm, leader’s objectification of women and admissions of sexual assault, for which millions of voters inexcusably gave him a free pass, are exacerbating matters. In an effort to flee weight stigma and oppression, people run towards a diet culture that damages relationships with food, increases eating disorder risk, and – ironically – promotes weight gain and worsened health.

Politics are not just about which bubbles each of us fill in on election day. Our positions reflect how we move about the world and what we want not just for ourselves, but for our friends, neighbors, strangers, the generations that will come after us, and of course our patients.

Nutrition is political, and our stances regarding the latter are intertwined with how we approach our work. We believe that everybody – regardless of their gender, size, weight, religion, country of origin, wealth, lifestyle behaviors, ethnicity, language, mobility, or sexuality – is deserving of respect, informed consent, and affordable access to evidence-based healthcare as a matter of human rights.

He Said, She Said: Clean Eating

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He Said

The phrase “clean eating” never arose in nutrition school, and the only time I have seen it appear in a peer-reviewed journal article was in reference to behaviors that could be described as disordered eating. That should tell us something.

Pop culture nutrition is, after all, quite different from scientific nutrition, and “clean eating” resides squarely in the former. Given the nature of “clean eating,” let us look in that direction for its definition. “Clean eating is a deceptively simple concept,” according to Fitness Magazine. “Rather than revolving around the idea of ingesting more or less of specific things (for instance, fewer calories or more protein), the idea is more about being mindful of the food’s pathway between its origin and your plate. At its simplest, clean eating is about eating whole foods, or ‘real’ foods — those that are un- or minimally processed, refined, and handled, making them as close to their natural form as possible.”

Unsaid is the prevalent cultural implication that “minimally processed, refined, and handled” foods – “clean” foods, in other words – are healthier than foods that do not fit this description. While the concept of emphasizing foods that are less processed has some merit, the message is so oversimplified and rounded off that it is more problematic than useful.

For someone trying to keep his blood sugar steady, whole grains might be more conducive to achieving this goal than more refined grains would be because the former tend to be higher in fiber and protein compared to their white counterparts, which are stripped of these nutrients during processing (although these nutrients, and others, are sometimes added back via fortification).

In other cases though, foods that are more processed might actually be the better choice. For example, I think of one of my patients, a young woman who had lost her period for many months due to nutrient deficiency, and it was not until we increased her intake of more-refined foods – which tend to be more calorically dense – that her period returned.

What constitutes a healthy choice for someone really depends on the individual, their needs, their preferences, and other factors that are unique to them. One of the problems with the way our society talks about food is the individual gets lost. For example, we talk about foods being “good for you” or “not good for you,” but who is the “you” in question? Almost always, the phrases refer to a monolithic representation of the population that probably does not take into account the unique characteristics that separate each of us from the pack. Talking in generalities has its place (No matter who you are, drinking paint thinner is not good for you.), but way too often that kind of oversimplified talk is misleading at best and damaging at worst.

Consider the good/bad food dichotomy embedded within “clean eating.” Foods unworthy of the “clean” label are, what then, “dirty”? If you have ever dieted, remember what it was like to consume foods that were frowned upon in the context of the diet. Most likely, ingestion of a small amount of a forbidden food triggered overconsumption of said food, not because of any objective qualities inherent to the food, but rather because of the overarching subjective eating experience. We eat a little bit of “dirty” food, figure today is ruined anyway, so we might as well have some more – whether we intuitively feel like more or not – and resolve to start over “clean” tomorrow.

Clean vs. dirty, good vs. bad, sin vs. virtue, these are issues of morality and spirituality that have infiltrated the world of nutrition. Alan Levinovitz, a religion professor who has taken to writing about nutrition in recent years because of the intersectionality of spirituality and food, explains, “It’s terrifying to live in a place where the causes of diseases like Alzheimer’s, autism, or ADHD, or the causes of weight gain, are mysterious. So what we do is come up with certain causes for the things that we fear. If we’re trying to avoid things that we fear, why would we invent a world full of toxins that don’t really exist? Again, it’s about control. After all, if there are things that we’re scared of, then at least we know what to avoid. If there is a sacred diet, and if there are foods that are really taboo, yeah, it’s scary, but it’s also empowering, because we can readily identify culinary good and evil, and then we have a path that we can follow that’s salvific.”

Hence, we invent a construct of “clean eating” that is based less on science and more on profound issues of humanity. Understandable as this behavior may be, I cannot say strongly enough: Our relationships with food become much less fraught when we remove issues of moralization, sin, and virtue from our food choices and eating behaviors.

 

She Said

Many of my patients with eating disorders (EDs) and/or disordered eating have engaged in “clean eating” at some point in their lives. The practice of eating only unprocessed, organic, additive-free foods that have the highest nutrient value seems to be the diet du jour for many people right now. And I get it – many of us want to live the longest and healthiest lives we can, and one of the ways we can take care of ourselves is by being aware of what food we put in our bodies. Take a look at any viral “food science” article or video online and you will hear doctors, dietitians, and other health care practitioners and researchers telling you that if you eat this one food (or don’t eat this one food), you can expect to live longer (or die sooner) – as if every food decision we make over the course of the day has the power to lengthen or shorten our lives. It makes it seem like we have so much control over our health, that if only we eat the right things, we will never have illness and will live forever. Of course, this is just not true (case in point: fitness guru Bob Harper’s recent heart attack).

Given the oversimplified and misleading fashion in which food-related information is often presented in the media, nutrition must seem like an ever-changing landscape. Sure, the field is evolving just like every other facet of health care, but not as radically or quickly as the public is led to believe. Every month, a new “super food” is unveiled and promises to improve our energy, stave off cancer, prevent heart disease, and so on and so on. Never mind that just a month earlier this food might have been on the “unhealthy” food list (I’m looking at you, coconut oil.). The point is that nutrition is always evolving, and trying to keep up with all of the foods we “should” and “shouldn’t” eat is exhausting. Yet, so many of my patients are obsessed with eating only the most nutritious, healthiest foods. They emphatically believe that some foods are inherently virtuous and clean, worthy of being ingested, while other foods are a waste of money and have no business being called food. And I believe that this is a big problem.

Food is not just fuel. Let me repeat this again. Food is not just fuel. Food is connection; it’s tradition, rituals, and how we care for ourselves and others. Food can elicit some of our most cherished memories (e.g., grandma’s famous chocolate chip cookies), and food can comfort us at times. I know that “emotional eating” has been deemed a problem by many, but really, it’s okay to eat emotionally at times. In fact, it’s completely normal! For people with EDs and disordered eating, sometimes the act of eating food can be agonizing, physically, emotionally, and mentally. I can’t count how many times I have heard some version of the following from my patients: “I wish I didn’t have to eat food, that I could just get all of my needed nutrients from an IV. It would make life so much easier.” These types of sentiments break my heart.

For individuals with EDs or disordered eating, breaking foods up into “good/bad” or “clean/unhealthy” categories is de rigueur. By having clear-cut rules about what is okay and not okay to eat, these individuals feel safer and in control (Of course, we know that really, the opposite is true – these rules control the individual.). In my work with my patients, I try to help these patients challenge their food rules. This might be having them eat a formerly loved food that they have not allowed themselves to eat due to perceived lack of nutritive value. We will also discuss the value of eating a wide variety of foods, that all foods fit, even Oreos. For most of these patients, they feel that eating less-nutrient-dense foods is a waste of time, that they are “empty calories” and have no business being eaten. I have had to justify more times than I can count why Oreos might sometimes be a better choice for a snack than an apple.

What it comes down to is this: Is eating “clean” really improving your life? Aside from perhaps improving some physical health markers, how are the other aspects of your life? Are you able to share meals with others? Are you able to partake in your child’s birthday cake? Are your food rules running your life or limiting it? These questions are what I would ask a “clean eater” to consider.

He Said, She Said: Whole30®

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He Said

Earlier in my career, I worked at a medical clinic where part of my job was to put people on a 28-day “detox” program, when ordered to do so by the doctors, for reasons ranging from digestive woes to problems with fertility. For those four weeks, the patient abstained from gluten, dairy, soy, eggs, peanuts, shellfish, corn, and other foods deemed to inflame the body. At the end of the four weeks was the possibility of reintroducing the forbidden foods in systematic fashion in hopes of determining the impact of each.

If the protocol, rationale, and reasons for use sound familiar to you, that may be because they are all strikingly similar to those of the Whole30® program. “Strip them from your diet completely,” the Whole30 program’s website says of the demonized foods. “Cut out all the psychologically unhealthy, hormone-unbalancing, gut-disrupting, inflammatory food groups for a full 30 days. Let your body heal and recover from whatever effects those foods may be causing. Push the ‘reset’ button with your metabolism, systemic inflammation, and the downstream effects of the food choices you’ve been making. Learn once and for all how the foods you’ve been eating are actually affecting your day to day life, and your long term health. The most important reason to keep reading? This will change your life.”

Oh, Whole30 might change your life all right, but perhaps not in the ways that you hope. Let’s take a closer look at the program and examine three questions that address how the claims and expectations stack up against what really happens when someone embarks on such a journey.

(1) Are the excluded foods (added sugar, alcohol, grains, legumes, dairy, carrageenan, monosodium glutamate [MSG], and sulfites) really “psychologically unhealthy, hormone-unbalancing, gut-disrupting, inflammatory food groups”?

In short, no, the connection between food and our bodies is not that simple. Taking a step back in order to gain a macroscopic view of life, we see that few of us are comfortable with murkiness and uncertainty, and this overarching theme weaves its way through our relationships with food. Our yearning for crisp delineations leads to an oversimplified good/bad food dichotomy that might make us feel at ease, but really, it is nothing more than the application of scapegoating to nutrition.

Alan Levinovitz, a religion professor who has taken to writing about nutrition in recent years because of the intersectionality of spirituality and food, explains, “It’s terrifying to live in a place where the causes of diseases like Alzheimer’s, autism, or ADHD, or the causes of weight gain, are mysterious. So what we do is come up with certain causes for the things that we fear. If we’re trying to avoid things that we fear, why would we invent a world full of toxins that don’t really exist? Again, it’s about control. After all, if there are things that we’re scared of, then at least we know what to avoid. If there is a sacred diet, and if there are foods that are really taboo, yeah, it’s scary, but it’s also empowering, because we can readily identify culinary good and evil, and then we have a path that we can follow that’s salvific.”

(2) The Whole 30 website reads, “We want you to take this seriously, and see amazing results in unexpected areas.” What about that?

One of the confounding factors, and indeed one of the greatest challenges, with elimination diets is the power of suggestion inherent to unblinded experiments. If someone wants to test if dairy is responsible for whatever symptom is ailing him, he might first cut out dairy, wait for the symptom to subside, and then add back dairy systematically to see if the symptom returns. He knows whether he is pouring himself a glass of cow’s milk or a dairy-free alternative though, and this knowledge can influence the presence or absence of the symptom in question via placebo or nocebo effects.

For example, consider the patients I wrote about a few years ago who told me how much better they felt after cutting out gluten while they – unbeknownst to them – were still consuming gluten in abundance. They expected the exclusion of gluten to produce a positive result, so the mere belief that they had done it created the desired outcome.

By scapegoating the to-be-excluded foods before the program begins, Whole30 builds expectations that their removal will yield positive results. By guiding participants to consider “results in unexpected areas,” the program throws a bunch of crap against the wall, assuming some of it will stick. You may remember that scene in Ghost in which the psychic, played by Whoopi Goldberg, offers name after name until she hits on one that her client – who fails to see through the sham – recognizes and takes as proof of a metaphysical connection to the afterlife. Similarly, the likelihood is that over the course of 30 days, at least one facet of your wellbeing will improve, even if temporarily, and Whole30 is banking on you giving credit to the program when in fact another factor could very well be responsible. 

(3) What happens beginning on day 31 and beyond?

“We cannot possibly put enough emphasis on this simple fact—the next 30 days will change your life,” the Whole30 website reads. “It will change the way you think about food, it will change your tastes, it will change your habits and your cravings. It could, quite possibly, change the emotional relationship you have with food, and with your body. It has the potential to change the way you eat for the rest of your life.”

If your expectation is that after 30 days of abstinence, you will no longer have the taste for or cravings for the foods you excluded over the past month, you will probably be quite disappointed. “A review of the literature and research on food restriction indicates that inhibiting food intake has consequences that may not have been anticipated by those attempting such restriction,” wrote Janet Polivy, a psychology professor at the University of Toronto. “Starvation and self-imposed dieting appear to result in eating binges once food is available and in psychological manifestations such as preoccupation with food and eating, increased emotional responsiveness and dysphoria, and distractibility.”

In other words, you will likely be drawn to the excluded foods more than before the program began and overconsume them. The overeating further reinforces your preconceived notion that these foods are a problem. You may even begin to believe that you have a “food addiction” and eliminate the food again, not realizing that your presumed treatment is exacerbating the supposed problem.

Back in my days of implementing the 28-day detox program, such rebound eating was commonplace, and I had many repeat patients who did the detox over and over again in the earnest belief that the latest attempt would turn out differently than all of the ones that came before it. They blamed themselves when really the program was a setup for failure.

Taking a look at the Whole30 website, I see similar red flags planted to expunge the program of responsibility while erroneously placing the blame for potential failure squarely on the shoulders of participants. “Don’t you dare tell us this is hard. Beating cancer is hard. Birthing a baby is hard. Losing a parent is hard. Drinking your coffee black. Is. Not. Hard. You’ve done harder things than this, and you have no excuse not to complete the program as written,” the site reads. “Don’t even consider the possibility of a ‘slip.’ Unless you physically tripped and your face landed in a box of doughnuts, there is no ‘slip.’ You make a choice to eat something unhealthy. It is always a choice, so do not phrase it as if you had an accident.”

See through the enticing marketing and realize that diets like Whole30 are unlikely to produce long-term positive results and are more likely to pave the way for weight cycling and an unhealthy relationship with food while making you feel responsible for their failures.

 

She Said

While the Whole30 program has been around for a few years (It was created in 2009 by two “sports nutritionists.”), it feels like I have been hearing a lot more about it recently. And since we recently rang in the New Year, there seemed to be a surge of Whole30 talk both inside and outside my office. Many of my patients have asked me about the eating plan that emphasizes eating “whole” (i.e., minimally processed) foods while avoiding dairy, soy, sugar, alcohol, grains and legumes for 30 days and then strategically reintroducing these foods one by one to see how they affect one’s health, energy and stress levels. One patient of mine is getting married this month, and her husband-to-be and many of her family members are following the Whole30 to start “shedding for the wedding.” Go on any “healthy eating” Instagram page and you will find #Whole30 all over the place, with people posting their “clean” meals and extolling the virtues of this way of eating.

As you can guess, I am not a fan of Whole30, or any fad diet for that matter. Not only is it just another way for someone to try to manipulate their food using external rules to shrink their waistline, but it also promotes the “good food/bad food” dichotomy, which can lead to a lifetime of dieting and never having a healthy relationship with food or one’s body. For someone who is predisposed to developing an eating disorder (ED), following a plan like Whole30 could be especially dangerous because diets are often the gateway to EDs. In fact, many of my patients who struggle with EDs have tried Whole30 (or similar eating plans) and have found that it worsened their ED symptoms.

The tricky thing about the Whole30 is that on the surface it sounds good – the authors talk about the health benefits one can expect to reap by following the program and how eating unprocessed foods can improve one’s health and happiness. The plan suggests that there is a “right” and “wrong” way to eat and that if one follows their food rules, they will live a longer, healthier life. In a way, it kind of smacks of orthorexia (i.e., an obsession with eating in a “perfect” manner) to me, which is tricky, as a number of people want to eat “correctly” and view food simply as fuel for our bodies that should always be of the highest nutrient value. It’s not a bad thing to want to eat healthfully and reap the benefits, but I firmly believe that flexibility is key to developing a healthy relationship with food and one’s body. Eating Oreo cookies is not a death sentence, and eating fruits and vegetables will not necessarily lead to you avoiding dying from cancer. What matters is the overall makeup of our diets, recognizing that all foods fit and that sometimes cookies are the right choice in certain situations.

Diets are seductive – they make lots of promises about how you are going to feel, how your body will change, and how your health will improve. They tell you that by following this arbitrary set of rules, you will reach true nutrition nirvana, all of your ailments will subside, and you will become the best version of yourself. Unfortunately, this is rarely the case, and most people cannot follow such strict guidelines for more than a short while, leading them to backlash by eating all of the “forbidden” foods and feeling like a failure. The very nature of diets is temporary, and any results one experiences during the “honeymoon” phase of a diet will likely dissipate once the dieter cannot follow the plan anymore.

I discourage my patients recovering from EDs from trying a plan like Whole30. In my work with these individuals, I am trying to help them eventually learn to trust their own bodies’ wisdom, that their body will tell them what, when, and how much to eat if they listen hard enough (i.e., intuitive eating). Eating in a way that is enforced by a set of external rules, like Whole30 or any other diet plan, flies directly in the face of this intuitive eating philosophy and can derail progress for many individuals dealing with ED. My advice? Skip the Whole30 and find an intuitive eating specialist who can help you rediscover what foods work for your body and promote your health (mentally, physically, and emotionally).

Wins and Losses: Old Habits Die Hard

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The following piece was written by one of Jonah’s patients who wishes to only be identified as a 36-year-old male.

Befitting the New Year, you would think I’d be writing about my resolutions for 2017, but I have a win from this past Thanksgiving that I’d like to share.

A little about me

I was a dancer as part of a performing arts group, and I traveled throughout the world dancing and performing in various venues — some as big as football stadiums and others as intimate as a small conference room. I was very fortunate to have this experience growing up (I began performing at the age of 16 and “retired” at the age of 26.) and feel grateful to have the talent and courage to pursue this sort of lifestyle. I’ve been to almost every U.S. state (excluding Alaska and the Dakotas) as well as various cities around the world — Paris, Amsterdam, Taiwan, Yokohama, Toronto, etc. I loved seeing all the different cities and how different cultures interacted within themselves, with other cultures, and even with their surroundings.

As you can probably imagine, traveling the world was glorious, but it was not easy by any means. I lived out of a suitcase for 6 months at a time; missing family events while I was on tour was the norm; and our sense of “home” was based on how long we would be staying in Anytown, USA. We were also at the beck and call of the directors and the schedules they created. Rehearsals every day, 7 days a week from 9am to 6pm (or some days even later if we didn’t have a show); additional performances that really strained every minute for “ME” time; and when and what to eat (and usually how much to eat) were always decided for us. It’s not as bad as I just made it seem. Like I said, it was quite glorious. It was nice to not think about the outside world — everyday tasks were managed for me. It really allowed me to focus on why I was there: to be the best performer I could be.

Perfection is attainable…right?

Dancing, much like any other sport, is really tough on the mind, body, and spirit. To be the best, you really have to work hard and be committed to the craft (not to mention have good genes and be somewhat of a natural talent). After all, the producers don’t give solos to the 2nd-best dancer. Dancing is also very specific — there is only one correct way to stand in first position. Any slight variation thereof is, well, simply incorrect. One might perfect their skills in other sports (i.e., one might work hard enough to make 9 out of 10 free throws), but in dance, there is always something that can be improved. So the idea of dancing “perfectly” does not exist. Yet, to be accomplished in dance, you constantly strive for this perfection. The struggle to jump higher is real. Turn faster. Turn faster! TURN FASTER! Even though these pressures mainly came from within myself, I became so worried (and obsessed) about being the best that nothing I did was ever good enough. Somehow, I thought I could achieve something better than perfection.

This battle bled into all aspects of my life: from personal relationships and self-confidence to body image and diets. Especially the latter. I distinctly remember a moment during the high point of my career. We were in dress rehearsal, putting together the finishing touches before our big opening night. At this point, we were all dancing 7 days a week for 6 to 7 hours per day. I was in peak fitness. I also wasn’t eating much because there was a portion of the performance where the men had to perform shirtless, and well, I was self-conscience about that since I wanted to look perfect. I mustn’t have weighed more than 130 pounds (I’m 5’10”.). My director approached me and suggested I watch my diet for the next few days because I would be standing next to some of the other men. She glanced over at the skinniest performer. She didn’t need to say the words, “and you are bigger than he is,” as the look was enough for me to really think about what I was doing and, more importantly, why I was doing it.

That moment was so pivotal to my career as a dancer. For me, dancing was like having a relationship with a double-edged sword. I loved to dance and was so passionate to share that with the world. I was enamored by the craft, while being pricked by both ends, as dancing created an environment that allowed me to neglect healthy eating and nutrition choices. I have trouble dealing with and embracing my own body image (The constant critiques towards a dancer are never-ending.); I struggle with the concept of working out to live a healthy life versus exercising to burn calories/lose weight; and even more, I have a hard time figuring out how to tune in to my body to find what I want to eat, when to eat it, and, more importantly, when to stop eating because I’ve reached an acceptable level of fullness.

Now (over 15 years later), my life is completely different. I’m not dancing anymore, so there’s that. I knew I wasn’t going to be able to dance into retirement, so I decided to pursue a different career and won’t bore you with those details now…just know that my life as a world traveler is much less exciting. What is exciting though is that I’m the leader of my own ship. I am in control of how my story goes, and I’ve come to love this freedom in most aspects of my life.

Setting expectations

Years following, I had the hardest time staying “in shape” — I would try any sport that would help me keep the pounds off: yoga, running, triathlons, obstacle course races. And even though all the training helped to maintain my body shape, I was still unhappy with the results I was experiencing. After talking to my sister-in-law about her nutritionist, I thought I’d give it a shot.

You should’ve seen me in my first session with Jonah — looking back now, I think it was quite comical — I came into the office, strong and confident, ready to establish expectations for our future work. I said, “Listen, you can put me on any kind of diet, but I won’t give up my sweets. I love them too much!” I didn’t realize I had the experience all wrong — it wasn’t about the sweets. I would then be educated about the different theories of nutrition, their applications, and the work I had ahead of me.

During our sessions, we would work on binge eating, recognizing fullness, honoring my hunger, and celebrating my relationship with food. We talked about embracing my body image and what that meant for me. We formalized strategies for upcoming occasions where my old habits would challenge my new relationship with food. Most importantly, we didn’t give up my sweets!

So…about that win!

As I mentioned earlier, I have trouble accepting my level of fullness. I went from being told what to eat to complete eating freedom, so you can imagine the binge eating every Thanksgiving, year after year, leaving the dinner table filled to the brim with stuffing, cranberry sauce, and mashed potatoes. You name it, I would eat it — if I didn’t really like the taste — or even if I was already full — or because there was something about missing out on the taste that I couldn’t let go — or because I didn’t want to upset the host by not eating the food they’d so lovingly prepared for us that day.

I wanted this Thanksgiving to be different from previous years, however. This year, I came to dinner with a plan on how I was going to eat during this meal, and I was determined to stick to it! (Spoiler alert: I did!)

Plan of attack

Through my work with Jonah, we were able to formulate a plan, and it was simple (in theory). I was going to take an inventory of the available foods during our Thanksgiving feast. As I walked around, I recognized foods that were appealing to me — I really tried to tune in to my intuitive eating skills — and what foods I could skip out on. I say “in theory” because by doing inventory, I also had to accept the foods that were appealing and give myself permission to eat those foods without guilt (For the record, I love bread and butter…lots and lots of butter.).

The result: I don’t really like all three varieties of stuffing, I don’t need to eat them all, and no one was going to heckle me about trying them all. Most everyone else was too busy serving themselves anyway. This quick walk-through allowed me to really honor and respect my hunger. It gave me the opportunity to carefully select the foods I was so excited to eat — it was Thanksgiving after all.

For the first time I can remember, I left Thanksgiving dinner feeling comfortable in my own skin (and clothes) by not overeating. I am still on the high from this win, and it helps give me confidence going in to whatever meal comes next. It might not be the most exciting win, nor does it mean I am over battling my other eating issues. But it is a “W” in my column.

Don’t get me wrong

I have good days and bad days. There are days where I eat multiple times throughout the day without ever consulting my intuitive eater. There are times when I feel like I really need to get to the gym to burn off that cookie I had earlier. Even though my day-to-day’s nutrition success fluctuates, what I’ve realized is that it’s a work in progress, and I won’t deny myself (and you shouldn’t either) the ticks in the “W” column (the everyday wins). I’ve earned that “W” and proudly display it on my sleeve (Ok, not literally. I am writing this anonymously, so if I wore a “W” on my sleeve, it might give me away.). You should too. No matter how big or small.

The Struggle Is Real

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The following is a guest column by one of Joanne’s patients, Ashley, a 28-year-old female. We sincerely thank her for sharing her story.

Processed foods.  Whole foods.  Organic.  GMOs.  Good Foods.  Bad foods.

When did all of these labels become so powerful? When did we stop listening to what our bodies wanted to eat, rather than what the media deemed appropriate? If you are a person living in this country, my guess is that your food intuition got drowned out somewhere in your childhood/adolescent years. For many, once we gained the wherewithal to understand the outside world and the messages being thrown at us via TV, radio, internet, we were no longer allowed to listen to our bodies and were told the “right” and “wrong” ways to eat. Or maybe you are one of the rare people that maintains a healthy, nonjudgmental relationship with food. If so, please don’t change your ways; you are unique and courageous.

Let me start by saying that I have been in recovery from a restrictive eating disorder for about three years. At the height of my eating disorder, I felt as though I could not escape the judgmental voices in my head that were only amplified by the outside messages I was receiving. I have never been considered an overweight child or adult, but at a young age, I became hyperaware of my food habits and developed an overwhelming fear of being fat. Growing up in an affluent town, where the pressure to succeed in every way, shape, and form became the standard, maintaining a “thin” ideal was the only way I felt I could succeed, as I did not believe I was successful enough in my studies at school. I was very studious and maintained As and Bs, but this was not comparable to the others around me in high-level AP courses with perfect scores. With this frame of mind, I turned to food restriction in the hope that if I couldn’t be the smartest, I would strive for the “perfect” body instead – whatever that even means.

I later learned that food would become a perceived source of control for when anxiety took hold in my life. Generalized anxiety, with a bit of obsessive compulsive behavior, is a genetic component of my brain chemistry that I inherited; it is a feature I share with others in my family. This seems to be a common theme amongst those with eating disorders, and thus I am not unique in this. My life became consumed with thoughts of food, body image, and the fear of becoming fat. I never thought I was dieting, just “eating healthy.” Striving to increase fruit and vegetable intake, and getting physical activity, in and of itself is a great thing. However, it is commonly a gateway mindset to disordered eating. What most people don’t understand is that an eating disorder is not something that is chosen or easily reversed. A lot of people have said to me “just eat,” or “you have nothing to worry about; you’ve never been overweight.” Trust me, I would not choose a life full of counting calories and innate voices telling me that if I maintain my thinness, I am a better, more beautiful person. That is an insurmountable amount of pressure to be put under, so no, I did not choose to think and act this way. Of course, an eating disorder, while potentially deadly in its own right, is not necessarily a terminal disease, and for that I am very grateful, but that does not mean my story is any less important or challenging. It is a taboo social/mental health issue that we don’t often discuss (until most recently), but I would like to put an end to that. Many of us suffer in silence with voices telling us that we are not thin enough, or that if we put on weight, we will not be loved. I myself did not have the discussion with many of my closest friends until a year or more into recovery.

I can tell you that although I have come a remarkably long way in my journey to recovery, these voices never go away; they only get quieter. I have come to terms with the fact that this may be my own destiny, but that doesn’t necessarily mean food has to run my life in a negative fashion. It has been embedded into our brains as a society that there is a certain way to eat, and not to eat. For some reason, food has gained a moral power, and we are judged on character by what and how much we eat on any given day. For those of us who have struggled with any form of eating disorder, it feels nearly impossible to ignore the flood of messages we receive on an hourly basis regarding food choices. For some, it may be easier to block these harmful messages out, and for that, I am envious.

By nature, I am an easy target for the influence of what I refer to as “Ed” (as in Eating Disorder), the alter ego voice that reinforces negative and irrational food thoughts and behaviors. I was an insecure child growing up in a high-pressure minicosm within a larger society that places increasing value on the “thin ideal.” Trying to navigate the steps to recovery has felt impossible at times in the modern-day era, where food and body size remains a constant topic of conversation. This hyperawareness of food is a fairly novel phenomenon. The seemingly harmless recipe blogs found on Pinterest, fitness blogs, and health research articles have grown in numbers, highlighting the fact that food obsession has become the norm. There have been periods in recovery where I had to deactivate my Facebook account and/or unfollow certain websites in order to regain my sanity and focus on what works for MY body and holistic self. The number of conflicting (and often untrue) facts and opinions on the “best,” “healthiest,” “clean” diets, available at our fingertips is more harmful to achieving a “normal” food mentality than we realize. Even something as seemingly innocent as family, coworkers, and friends asking what I was having for lunch or dinner, or what was in the lunch I brought to work. The analysis and chatter regarding food trends and health is inescapable, and when I took a step back and became aware of it, I recognized my OWN disordered comments with others. I became more sensitive to asking others about their food habits, or how I complimented them, such as the common, well-meaning “Wow, have you lost weight? You look great!” The number of disordered messages that this single statement holds is often overlooked, as weight loss is praised and often equated with beauty.

A very tricky component of my recovery process is that I enjoy cooking (and have to say I am quite decent at it). I often justified cooking my own meals because it was cheaper and “healthier.” Now while that is certainly true, I now realize that measuring and calorie counting every morsel of every meal provided me with an immense feeling of control. I continued with these obsessive thoughts and behaviors for over 3 years, and only about a month ago did I literally throw out any form of measuring cup or spoon. Over the past year, I began forcing myself to eat out once a week or more, where I couldn’t count calories or micromanage the ingredients in whatever I ordered. What I have learned in regards to this is that control feels safe, but rebellion is uncomfortable, and progress often does not occur without discomfort.

In my recovery process, the practice of “intuitive eating” has truly given me hope. For those of you who are unfamiliar with this style of eating, it is basically a practice of getting in touch with your body’s needs, wants, cravings, and satiety. Instead of “how many calories are in this sandwich?” or “how many calories have I eaten today?” the focus shifts to “what is my body in the mood for, and how can I create that? What type and quantity of food is going to make me feel nourished and energetic?” I have to say that honoring my hunger intuitively has been one of the most difficult challenges throughout the recovery process, but without a doubt, the most rewarding and satisfying. Eating without internal judgment? I have never known what that feels like or what it truly means. I may never fully recover from my eating disorder and have come to terms with that idea. However, I continue to learn about my body and coping skills in ways that I never thought possible. I will continue to have great days and very anxious days, but overall, I can say with confidence that life is truly brighter when food freedom feels just within my grasp.

“If you’re gay, don’t come home.”

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Joanne and I overhear so much nutrition-related garbage at our health club that I have considered creating a new blog category to chronicle it all, the working title of which is “Shit We Overhear at the Gym.” Harsh, but to the point.

Similarly candid and blunt was my experience at the gym this morning, where the topic of conversation was understandably a departure from the typical diet talk, body shaming, and nutrition myths, and instead focused on the presidential election results.

“My husband told me, ‘Anybody but her [Hillary Clinton]’, but I am really scared, and as a woman I feel so disrespected,” said the woman on the cable machine. Shortly thereafter, I ran into a friend of mine who fought back tears as she talked about what Trump’s election means for her 18-year-old daughter who now fears for her present and future.

Once I finished my workout, I headed downstairs to the men’s locker room where the guys were also discussing the election, but instead of crying they were laughing, making a joke of the whole thing. The sample size is small, granted, but the stark contrast between the male and female reactions illustrates the difference between the privileged and the vulnerable.

A friend of mine, someone I have known for close to 30 years, is the only open Trump supporter in my social circle. Once his candidate was declared the victor, he took to Facebook and gloated. After considering whether or not to respond, I decided to reach out to him in a way that I thought might help him to understand what this election result really means for our country.

When we were teenagers,” I wrote, “your father reportedly said to you, ‘If you’re gay, don’t come home.’ Fortunately, you self-identified as heterosexual, but the threat of not being accepted and welcome in your own home shook you enough that you talked with me about it. A Trump presidency makes America a less welcoming and more dangerous place for Muslims, Jews, Mexicans, women, blacks, gays, and other at-risk groups. The outrage and fear we are witnessing regarding Trump’s election is not about political parties, a change in direction, or disagreement over policies; rather, it is about millions of people with whom you and I share this country waking up today worried for their safety and freedom.

“For your sake, I am glad the crosshairs are not on you, at least not yet. Hopefully neither one of your sons is a closeted homosexual or self-identifies as a woman but is too scared to say so. For the rest of us, whether we are members of one of Trump’s targeted groups or we simply care about the people who are, his election is an ominous reminder that hate and scapegoating are alive and well in America and that history can certainly repeat itself.”

Hate is nothing new and Joanne and I have received a small taste of it. Because we advocate for size acceptance, we are occasionally bullied by online trolls who disagree with our stance that everybody, regardless of their size, is entitled to respect and equal treatment. The flack that we catch is nothing; for some of our colleagues, daily death threats are a way of life.

What is new though is the legitimacy that Trump has given to hate. Hiding behind an anonymous Twitter handle or a white sheet was one thing, but suddenly we had a presidential candidate repeatedly broadcasting his racism, misogyny, and bigotry out in the open on international television, and instead of shutting him down, we elected him. No wonder the women in the fitness center cried while the guys downstairs laughed.

As paradoxical as it may sound, intolerance of intolerance is an important stance for the safety of our community. Employees who spout hate speech at work are likely to be disciplined or fired, our legal system has hate crime laws that extend beyond whatever act is committed, and Germany banned the swastika after the fall of the Nazi regime, just to name a few examples. Regarding the latter, I reminded my friend how things worked out for that country and its people when a man rose to power on the platform that minorities were to blame for the nation’s poor economy and lack of prosperity.

We, as Americans, should be ashamed of ourselves. All of the men and women who have given their lives, either literally or figuratively, in military conflicts and civil actions over the past 240 years in pursuit of freedom and equality, and now a good portion of our citizens are eagerly trying to flush it down the toilet. We are a threat to ourselves and the world. America is an international embarrassment.

Joanne and I both want to leave. She says Toronto, I say Canada is too close for comfort and have my sights set on New Zealand. In reality though, running from the problem is no solution and we are not going anywhere. Every generation faces its struggles with hate, but the overall trend moves towards acceptance and inclusion because ordinary people hold their ground, stand up, and demand it.

Gentlemen, the Ladies Do Not Hold a Monopoly on Weight Obsession

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Gentlemen, the ladies do not hold a monopoly on weight obsession. Us guys engage in diet talk and body shaming, too. You know that, right? Maybe not, actually, as such talk is so casual and commonplace that you might not even be aware (consciously, anyway) of its pervasiveness. Consider the interaction I had yesterday evening at the gym with a male acquaintance we will call “Brad,” whom I had not seen in a long while.

Brad walked past me as I was warming up on the Arc Trainer prior to a tennis match. He had just finished a spin class and stopped to say hello. Brad and I first met 16 years ago while taking a core-strengthening class together, but the only place I had seen him in recent years was when we occasionally bumped into each other at the local pub where he eats dinner every Friday.

“You’re in nutrition. What do you order when you go there?” Brad asked with a smirk. Although he did not specifically say so, I knew exactly what he was getting at: He wanted to know if I follow a strict diet or eat freely like a perceived hypocrite, hence the mention of my profession.

Pausing, I considered the various replies at my disposal. On one hand, this was an opportunity to reeducate Brad regarding both the nature of my work and the problems with a good/bad food dichotomy. On the other hand, this was also my free time, and really I just wanted a few minutes to myself to get loose before heading out to the court, not an obligation to broach complex topics when I had neither the time nor inclination to do them justice.

“I order what I want,” I finally told him. “I order what feels like the best choice for my body at the time,” and specifically cited the pizza and nachos, which are my salty favorites to replenish the sodium I lose during long runs. (Note: By no means am I implying that one needs to exercise in order to “earn” these menu items or any other food.)

Then I asked him if he has seen our mutual friend (Let’s call him “Gary.”) who resumed exercising earlier this year after a long absence. “He’s down 40 or 50 pounds,” Brad responded, “He looks great!” Again, I paused and internally debated my next move. At the very least, I knew there was no way I would echo Brad’s praise for weight loss, as I know the damage such extolment causes, especially without fully knowing how or why someone lost weight.

“Weight loss aside, I’m just glad he is taking the time to care for himself again,” I told Brad. Like me, Gary was an avid exerciser, which is how he and I met at the gym soon after I graduated from college, but the burden of his caretaking duties increased as the health of his parents deteriorated and he no longer felt up to working out. His mother and father subsequently passed away in quick succession, which left Gary to settle their estate and figure out what to do with his own life. After everything Gary had been through, I was just happy to see him caring for himself again and returning to the activities he enjoys, including exercise, regardless of his weight.

Unfortunately, Brad did not seem to follow the gist of my sentiments and continued talking about Gary’s weight loss, adding that he has seen Gary do this at least a few times before. By “this,” Brad was referencing Gary’s history of weight cycling: alternating periods of weight loss and subsequent regain. “But not like you have to worry about that yourself,” Brad offered, looking down at my abdomen. “You’re always in great shape.”

Great shape? One of the problems with judging people for their exteriors is that we probably have no idea about the makeup of their interiors, both metaphorically and literally. Too taken aback by Brad’s comment to say anything out loud, I silently reflected upon everything I have been through over the last three years and specifically turned my thoughts to the titanium screws and rods, artifacts from my third back surgery, buried deep inside the midsection of which Brad is apparently so envious.

As is the case for everybody, my size and shape are influenced by many factors, the most significant of which are out of my hands. Among those that are at least somewhat in my control though is my history of never having tried to lose weight, which would have put me on a path most likely to end at, ironically enough, weight gain. In that sense, part of the reason I do not have a “weight problem” is because I never viewed my weight as a problem.

Think about the diet talk and various mentions of body shape and weight that Brad crammed into a casual conversation that lasted just a few minutes. Comments and discussions along these lines are so prevalent that I overhear men talking this way at the health club on a daily basis. Another recent incident comes to mind in which some of my fellow tennis players – adults, no less – bullied another player for the size of his stomach.

The problems with such talk are numerous, including: the reinforcement of the ridiculous, offensive, and dangerous notion that people of certain sizes and weights are more deserving of respect than others; the exacerbation of bullying and unequal treatment that spills well beyond health clubs and into our homes, businesses, classrooms, government initiatives, and doctor’s offices; and the pressure to pursue weight-loss endeavors that most often result in weight gain and worsened health.

Guys, this kind of talk has to stop, and the first steps toward putting it to rest are acknowledging its existence and realizing the harm we are doing to each other through our words.

One Week in October

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October 15, 2016, Ludlow, Massachusetts

Exactly 941 days after my first spinal fusion and 472 days after my second, I drove west to play a match for my old Amherst-based United States Tennis Association (USTA) team for the first time in a decade.

Over those 10 years, and particularly in the last two as I recovered from my operations, I dreamed of reuniting with them and wondered if it would ever actually happen. Intellectually, I thought it might, as my surgeon was cautiously optimistic about my chances of playing competitively again. My physical therapist was more guarded, however, particularly because the failure of my 2014 surgery reinforced that medical outcomes are rarely guaranteed no matter how certain they may seem on paper. So while in my head I thought I might compete again, in my heart I never really let myself believe it for fear of crushing disappointment.

The team roster has undergone some turnover since I last played for them in 2006, but many men still remain from my first stint and it sure was great to see them again. “You haven’t changed at all!” one of them declared. Well, on one hand, I think of the transitions I have experienced in the last decade: no longer a student, now a licensed healthcare practitioner; no longer an apartment-dwelling bachelor, now a husband, homeowner, and business owner; no longer a spry 20-something, now a balding guy in the twilight of his 30s with three back surgeries under his belt.

On the other hand, I felt at home again, just as I had before, that much was constant, and I think my teammate could see it in my face. If anything, I felt even more confident walking onto the court now than I did back in the day. Just returning to the team was in itself a victory, so whatever else I happened to achieve in the match was a bonus.

Confident and relaxed, I took advantage of an opportunity a decade in the making and destroyed my opponent 6-1, 6-0. As I quipped to my team captain, “Those 10 years of rest really helped!” Most importantly, my back felt great before, during, and after the match, which was particularly noteworthy considering what my body went through just six days earlier.

October 9, 2016, Newport, Rhode Island

My surgeon cleared me to resume running in January and I quickly ramped up my training enough to complete a 10-mile race in late February, but subsequent pain suggested that sticking to shorter distances was probably in my best interest. As the spring progressed, however, I was able to comfortably go for some longer jogs, which had me wondering if running the Newport Marathon in October might be possible. In July, my surgeon reversed his stance on long-distance running, gave me his blessing, and told me to go for it.

Go for it, I almost did not, as I nearly backed out several times on the morning of the race. As recently as two days earlier, I was excited for the event and did not feel the slightest bit nervous, but in the final hours I was sad and anxious, eerily similar to how I felt on the mornings of my surgeries. Driving south on route 24 before dawn, I thought about how easy it would be to take an exit, any exit, turn around, head north, and crawl back into bed. Just continue on to Newport, I told myself. Do not make a decision about the race yet, just drive to Newport, park, and reevaluate.

The parking lot near the starting line was still pitch black when I arrived, and torrential rain and raging winds, the extension of Hurricane Matthew that reached New England, pummeled me as soon as I stepped out of my car. Retreating to my vehicle, I considered pulling out of my space and driving home. Instead, I paused to take a deeper look at my anxieties, which mostly centered around getting sick or injured, and reminded myself of the strategies I had formulated to avoid disaster and maximize my chances of a great race.

Most importantly, I remembered other instances in my life when I felt similarly stressed and apprehensive before significant events, most notably my transcontinental bicycle ride a decade ago, only to be happy that I had followed through. In the early morning hours of June 1, 2006, my best friend drove me to a Seattle beach, my bicycle and backpack in the trunk. Sometimes he reminds me just how petrified I looked as we sat there waiting for the other riders to arrive. Indeed, part of me wanted to curl up in the fetal position in his passenger seat and ask him to drive me back to Seattle-Tacoma International Airport. Out of the 4,024 miles I traveled between Seattle and Boston, the most difficult span was the step out of his car, but I am so glad I took it.

“If you get out and run,” I told myself, as I remembered my bike trip, “in about six hours you are going to sit back down in this car seat with a medal and a tremendous sense of accomplishment.” So that’s what I did: I got out and ran. Around mile 24, I passed by my car and thought about the pep talk I had given myself early that morning. Soaking wet from the storm but excited and still full of energy, I finished the course with the fastest two miles of my entire race.

As was the case regarding my aforementioned tennis match, my back held up just fine during the marathon. “I don’t know if you fully appreciate how impressive that is after all you have been through in the past few years with your back and the surgeries,” my physical therapist wrote in an email. She may be right, as she can speak better regarding typical clinical outcomes than I can, but by no means did I take being able to complete a marathon for granted. Finishing was emotional, not just because of how close I came to backing out of the race that morning, but because for a long time I thought I would never cross another marathon finish line again.

Three days after the race, I returned to my surgeon’s office for a routine follow-up appointment. “I brought something to show you,” I told him, as I reached into my jacket pocket and retrieved my finisher’s medal. “Wow,” he laughed, “That’s amazing!” Back in March, he had gently told me my days of running marathons were probably over. He was right; they probably were.

October 8, 2016, Boston, Massachusetts

Walking from the Hynes Convention Center subway stop to its namesake for the final day of the Cardiometabolic Health Congress, I remembered limping the same route three years earlier, physically unable to continually walk the two blocks without pausing for my back pain to die down.

About a week before that day in 2013, I went to bed feeling fine, but in the morning I stood up from bed and almost fell over due to a sudden onset of severe pain radiating down my leg. Over the next few days, I hoped the symptoms would resolve as spontaneously as they arose, that I would similarly go to bed and wake up in the morning feeling back to normal. As I struggled to walk from the subway to the convention center, however, reality set in that a rapid recovery was not in the cards and I might be in serious trouble.

Thus began my three-year saga of doctors, injections, medicines, physical therapy, alternative treatments, surgical consults, operations, setbacks, and rehab that led to the present. This road has no end, as I will always have to be mindful of my back, take care of it as best I can, and live with the uncertainty that someday I may run into trouble with it again despite my efforts, but I am very happy and thankful to be where I am today.