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My right hamstring was cramping up before I even left the house yesterday morning for the Newport marathon. How does that even happen? Nerves, probably. Marathons always make me anxious, but this year I went in with expectations, which compounded the anxiety.

My training went so well that I thought I had a shot at setting my all-time personal marathon best. No, it was more than that; I thought I had it in the bag, and it would have meant a lot to me to achieve a personal best after everything I went through with the surgeries.

Anyway, by mile five (Five!) both of my legs were legit cramping up, but I still maintained my goal pace for the first 18 miles before everything fell apart over the last eight. While I still beat my time from last year – which I ran during Hurricane Matthew – by a half hour, I was well off my expectations and nowhere near a personal best.

While we tend to only post on social media when things go well, privately we understand that not every day is a great day, not every goal is accomplished, and not every dream gets fulfilled.

Historically, Newport sea captains placed pineapples outside their homes to signal that they had returned safely from their voyages. With that in mind, my finisher’s medal offers perspective; while the race certainly did not go as I had hoped or expected, worse outcomes were possible, and at least I made it back home.

Sugar makes you fat?

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As a teenage cross-country runner, I believed that if I cut out dietary fat, I would reduce my body fat stores and therefore increase my speed. Besides, many other people around me were demonizing dietary fat, too. In those days, low-fat and no-fat were all the rage. The food industry was more than happy to capitalize on the fad, thus leading to grocery store shelves filled with fat-free products like SnackWell’s cookies, thereby perverting the notion that we were all on the right track to health while simultaneously enabling our disordered eating.

Unlike actual scientific evidence, popular-culture nutrition is fickle. The Atkins diet was hot while I was in nutrition school, but by the time I became a practicing dietitian, going gluten-free was the in thing to do. Hardly any of my patients back then actually knew what gluten was and where it was found, but they erroneously believed they had eliminated it from their diets and boy did they feel better.

Scarce are the people who fear dietary fat now, and these days fewer and fewer people seem wary of gluten, but now sugar is in pop culture’s crosshairs. This past weekend, Joanne played in a charity tennis tournament where she encountered a sponsor who was touting his sugar-free sports drink. “Sometimes people need sugar,” she reminded him, and also threw in that she is a registered dietitian. Offering a rebuttal that lands squarely at the intersection of pseudoscience and weight stigma, he offered, “Sugar makes you fat.”

Regarding the latter, I approached him by myself to see if he would make a similar comment to me, a male in a thinner body, but he did not seem interested in engaging me in conversation. “So, your product is essentially made to rival drinks like VitaminWater Zero?” I asked, but he just walked away. In fairness, he might not have heard me, as many players and staff around us were making quite a bit of noise.

With regards to the factual accuracy of his claim – or lack thereof – no, sugar does not make you fat; that is not how weight regulation works. Body weight is the result of many different factors, including, but not limited to: genetics, environment, medical conditions, and lived experience (for example, history of weight cycling). Eating and physical activity behaviors are of course part of the equation, too, but contrary to popular belief, our weight is largely out of our hands. In fact, a presenter at a conference I attended last year stated that weight is 90% as genetically determined as height.

Besides, Joanne was correct; people do need sugar. Your doctor most likely measures your blood glucose, a kind of sugar, at your annual physicals. If that number reads zero, you are dead. Even if it merely slips below the normal range, you are probably lightheaded, lethargic, and having difficulty concentrating, all symptoms of not having enough circulating sugar to fuel your brain and other organs.

While the rate of the reaction depends on the food in question and one’s individual body chemistry, our systems eventually break all carbohydrates – from sprouted ancient grains to neon gummy bears – into simple sugars. You can get a sense of this by chewing a piece of bread or cracker longer than normal. The sweetness increases the longer you chew because the salivary amylase, an enzyme in your saliva, is already breaking down the long carbohydrate chains into sugar.

Besides, creating a sports drink without sugar is somewhat head scratching. On one hand, I guess it makes perfect sense, just as fat-free cookies back in the 1990s sounded like a great idea, too. Both are cases of smart food manufacturers taking advantage of nutrition fads to satisfy consumer demand and thereby earning themselves quite a profit. Always remember that a food company’s priority is their income, not our health; product prevalence is only a gauge of demand, not the state of nutrition science.

Sports nutrition, in particular, is an area where the fear of sugar is hurting athletes. Carbohydrates and fat are the main sources of fuel during athletics. Even the leanest marathon runner has enough fat stores to provide sufficient amounts during their event, but our carbohydrate stores are much more limited, as we only tuck away small quantities in our liver and muscles in the form of glycogen. If we do not replenish our carbohydrates during exercise, we pay the price, as I can attest from personal experience. As a long-distance cyclist, only twice in my life have I failed to complete rides that I set out to do. The first was when I fell off my bike in Montana and fractured my spine. The other was a few years later when I was temporarily experimenting with a low-carb diet and became so fatigued that I could not make it home.

Much more recently, I went for a 21.2-mile training run in preparation for next month’s Newport marathon and consumed nearly two liters of Gatorade out on the road. Thanks in part to the approximate 112 grams of sugar keeping my energy up, I had a great run and could easily have kept going for another five miles had it been race day.

Back when I was a fat-avoiding teenager, my mom saw the red flags of disordered eating and brought me to a dietitian who explained to me that, contrary to popular belief, dietary fat was fine to consume and that cutting it out would hinder, not improve, my running. Now that I am on the other side of the counseling table, hopefully I can give you similar reassurance about sugar.

You have seen memes and headlines suggesting that sugar is toxic and maybe you have questioned if you have a sugar addiction. Perhaps sugar-free products sound like the path to salvation and virtue. Attempting to cut out sugar might feel like the right next step, especially when so many people around you are going down that road, but I caution you against such pursuits. Remember, soon enough our culture will be demonizing another nutrient, ingredient, or food group. Better to establish and retain a healthy relationship with food and let the fads fall by the wayside.

Are you doing intuitive eating wrong?

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He Said

First, a word about what intuitive eating is. In our culture, we are often taught that we cannot trust ourselves to guide our food choices. Instead, we use apps to track our calories and macronutrients, food models and sections of our hands to dictate portion sizes, and various books and online resources that tell us which foods to eat and which ones to avoid.

Eating based on external factors is problematic and often unnecessary. These behaviors instill and reinforce issues of guilt and deprivation regarding our food choices, and they also give the impression that some algorithm knows better than our bodies how we should be eating, which is typically nonsense.

Our bodies are actually quite good at guiding our eating behaviors – young children, for example, are generally great at knowing when, what, and how much to eat (that is, until we screw them up by teaching them to override these cues). We just have to get back to listening to and trusting our bodies again, and that is what intuitive eating is about.

The way I sometimes explain it to patients is to recall Maslow’s hierarchy of needs and discuss that in nutrition we have a similar structure. At the base, someone needs food. Period. If food security is an issue – and such scarcity can be brought on by external issues like finances or access, or they can be self-imposed, such as by dieting – then not much else matters. At the very top is medical nutrition therapy, which is how we eat in order to manage issues with our health, such as high blood pressure.

The middle layer is comprised of our relationship with food: How do we decide what, when, and how much to eat? People oftentimes want to jump right to the top, which is understandable. After all, if someone is concerned about a medical condition, of course they want to dive right in and talk about how they can help the issue through food. The problem, though, is that if we ignore the middle layer, then we do not have a proper context for incorporating the medical nutrition therapy, which can consequently come across as a diet.

Situations do exist in which jumping right to the top is the best course of action. If someone comes in with Celiac disease, for example, discussing matters like safe and unsafe foods, hidden ingredients, and cross-contamination will be high on our to-do list. The difference between this kind of scenario and most others is that with Celiac disease, the issue is more black and white: unsafe foods for this person really do exist and the patient must completely abstain from them. The same could be said for someone who comes in with a life-threatening food allergy.

In contrast, most nutrition-related conditions, including high cholesterol, high blood pressure, and blood sugar concerns, exist in a gray area. We have guidelines, but not rules, so the patient is going to have to make food decisions every single time they eat. Do they really want to be relying on some app, meal plan, or an oversimplified list of “good” and “bad” foods to tell them what to eat for the rest of their lives, or do they want to develop a healthier relationship with food that will enable them to incorporate the medical nutrition therapy in a way that still honors their hunger/fullness cues and cravings? That is why we focus on intuitive eating as a precursor to medical nutrition therapy.

With all that said, the most common way I find that people misuse intuitive eating is the belief that if they eat when they are hungry, stop when they are full, and eat the foods that their bodies seem to be asking for, they will automatically lose weight. This belief is understandable; after all, the idea of energy balance (calories in versus calories out) is so pervasive in our society that people just assume that if they reduce how much they eat, then of course they will lose weight.

In reality, while energy balance is certainly true from a thermodynamic point of view, our bodies are complex open systems, and the math is not as straightforward as our apps would have us believe. If someone consumes a 100-calorie slice of bread, the number of calories he actually absorbs from it will depend on factors such as his genetics and his gut microbiome, whereas someone else could eat that same slice of bread and absorb a different amount of calories. Furthermore, calories consumed affect our calories expended (Think of someone whose metabolism slows as a result of restriction.), so the two sides of energy balance are not as independent as many believe.

Despite my warnings, some patients still believe that if they just learn to eat intuitively, they will lose weight. Thus, they treat intuitive eating as a diet, which is a setup for failure. Time and time again, I have seen such people develop some basic intuitive eating skills early on, but their progress stalls as soon as their weight loss does. Someone might be able to keep one foot in the weight loss and intuitive eating worlds for a short while, but quickly this straddling leads to stumbling.

In order to extensively rediscover our intuitive eating skills, we absolutely must ditch any expectations regarding physical changes, such as weight or body composition, that our bodies will make as a consequence of our pursuits. In other words, if you are using intuitive eating to lose weight, then really you are just dieting, and the results are probably going to be as dismal as they would be with any other weight loss pursuit.

 

She Said

As many of you know, a lot of the work that Jonah and I do with our clients is around helping them become intuitive eaters. While on the surface the concept of intuitive eating seems quite simple – eat what you are hungry for in the amount that feels comfortable and satiating to your body – there are a number of complicating factors that can get in the way of an individual being able to do this. In some cases, even though an individual might truly want to be an intuitive eater, they might not really be able to do so. The clearest example of this is when I am working with patients struggling with eating disorders (ED).

When an individual engages in eating disorder behaviors, such as restriction, bingeing, purging, or overexercise, oftentimes this will take a toll on their digestive system and their ability to distinguish hunger and fullness cues. As such, I have heard from many patients that they either never feel hungry or never feel full (or in some cases, they cannot even describe what hunger/fullness feels like to them). Since being an intuitive eater depends on the individual being able to not only recognize their hunger and fullness cues but also be able to attend to these cues appropriately, those individuals with ED can find it to be nearly impossible to eat intuitively.

Patients who come to see me and are early on in their recovery process will often bring in with them a meal plan they have been following. In general, I am not usually a fan of meal plans, as I discuss here, but in some cases, they are necessary to help individuals with EDs reestablish their hunger and fullness cues. Making sure that the body is receiving 3 meals and a few snacks throughout the day helps to undo some of the damage that the ED has done to these cues. The body comes to expect that it will be fed at regular intervals; therefore, you will feel hungry at certain times. Feeling hungry periodically is a normal body process, a survival mechanism that tells you when your energy stores are low and your body needs fuel. When a patient with an ED goes long periods of time without eating or not eating enough, the body actually habituates to its hunger signals, and eventually the individual cannot even recognize or feel hunger. Meal plans are an essential step (for some) to get their body back into a natural rhythm of fueling their body when they are hungry.

Sometimes when I have been working for a short while with a patient struggling with ED, they will express the desire to try eating intuitively. While helping my patients become intuitive eaters is the ultimate goal in my work, it is not something I often dive into headfirst with my ED patients. On a number of occasions, I have had individuals try to eat intuitively too soon in their recovery process, and they will find themselves either not eating enough (as they still do not have accurate hunger cues) or eating more than their body is asking for due to a fear of getting hungry.

I like to encourage these patients to try out an approach that is halfway between meal plan and intuitive eating. To achieve this, I will use a “modified” intuitive eating meal plan as a stepping stone to intuitive eating. The plan typically involves having the patient eat every 3-4 hours (during waking hours, of course!) and making sure that they have carbohydrate, protein, fat, and either a fruit or vegetable at each meal. Instead of specifying that the patient needs to have X number of carbohydrate exchanges, I give more of a range (e.g., “have 2-4 carbohydrate exchanges at breakfast”) as this gives the patient some flexibility to eat more if they are hungry for it or eat a bit less if they are not. In a way, it is giving the patient some intrinsic choice around their food while still giving them the structure that their body needs. Once the patient has mastered this “in-between” meal plan for a substantial period of time, we would discuss trying to work on eating more intuitively.

In the end, the goal is to help my patients learn to trust their body’s innate wisdom – that it will tell them when they are hungry, what they are hungry for, and how much is enough to satisfy them. As long as the individual does not jump into intuitive eating too quickly (i.e., before they are ready), they will be well on their way to developing a healthier relationship with food and their body.

“Too Fat” vs. “Too Thin”

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Those of us who have had an eating disorder know firsthand that while recovery is possible, the road can sure be difficult. The eating disorder voice is powerful and can make people do and say things they otherwise would not express if their bodies and minds were in healthier places. A woman who is struggling mightily to recover from anorexia nervosa posted on a message board criticism of her treatment team for saying that being “too thin” is problematic while being “too fat” is okay. Does she have a point?

The treatments for someone who is “too thin” versus “too fat” are actually more similar than some people realize. In both cases, the etiology of the person’s size matters as well as whether or not the origin is pathological.

For example, consider two people, each of whom is “too fat.” One person has a healthy relationship with food and physical activity, no significant medical or psychological issues, has always been “too fat,” and comes from a family of people who are of similar builds. Meanwhile, the other person is “too fat” due to binge eating disorder. The former receives no treatment while the latter receives treatment for his eating disorder, not his body size.

Now consider another example of two people who are both “too thin.” One person has a healthy relationship with food and physical activity, no significant medical or psychological issues, has always been “too thin,” and comes from a family of people who are of similar builds. Meanwhile, the other person is “too thin” due to anorexia nervosa. The former receives no treatment while the latter receives treatment for his eating disorder, not his body size.

[Note: Anyone of any size can have an eating disorder, including some “too thin” people who experience binge eating and some “too fat” people who restrict. In reality, we never completely know what struggles someone might have just by looking at them.]

In both cases, whether one is “too fat” or “too thin,” any treatment is targeted at the underlying pathology, if one is present, not at the body size itself. However, for the person who is “too fat” due to binge eating disorder, we let the person’s weight take care of itself as they progress through treatment, as opposed to focusing on the weight. He may or may not lose weight as his disorder subsides, but altering his body weight is not the goal for two reasons:

(1) While being “too fat” is associated with an increased risk of medical woes, causal relationships have not been established, contrary to popular belief. In chapter six of Health at Every Size, Dr. Linda Bacon does an excellent job of explaining the correlations between body weight and the conditions for which weight is often blamed.

(2) While our bodies are relatively adept at gaining weight, they are resistant to long-term weight loss. In other words, interventions aimed at lowering body weight are most likely to result in ultimate weight gain, so in that sense even if the patient’s weight itself is the problem, he is only likely to exacerbate the condition by trying to lose weight.

In contrast, for the person who is “too thin” due to anorexia nervosa, weight restoration is an important part of his recovery. When someone becomes unnaturally thin due to restriction, overexercise, or other disordered behaviors, the body sheds not just fat mass, but also bone structure and tissue from organs, including the brain.

Dr. Ovidio Bermudez, Medical Director and Chief Medical Officer at the Eating Recovery Center, a behavioral hospital for children and adolescents, gave a talk at the 2014 Hynes Recovery Services conference in which he explained, “As a young girl starves herself, or a young man starves himself, and they knock off their sex steroid production, one of the important aspects of that, one of the downstream consequences of that, is that they may also be unintentionally impacting very important aspects of brain development, including neuronal growth.”

When discussing recovery, Dr. Bermudez noted that brain atrophy can be documented just as we can document bone demineralization, and then he continued, “If you stay underweight, your brain size does not recover. So you have to really normalize your weight in order for your brain size to recover.”

Dr. Kim Dennis, former Medical Director at Timberline Knolls Residential Treatment Center and current Medical Director at SunCloud Health, presented at the same conference and explained further, “When a patient with anorexia also says they’re depressed or a parent says they’re depressed, many times that’s not depression. That’s simply what looks like a mood disorder, but it’s based on the fact that their frontal lobes are shrunk, they can’t display affect, they have lower levels of neurotransmitters in their brain, and the cure to that, the treatment to that, is not necessarily Prozac, but it’s food and refeeding.

“Many times patients with anorexia really, really value their brains, and a lot of times you’ll tell someone with anorexia, ‘You’re not thinking straight because you’ve lost neurons. Your brain looks more like a 60-year-old with early dementia than an 18-year-old.’ And they’ll say, ‘I know a lot of anorexia patients might look that way but my brain doesn’t.'”

She then referred to a slide showing a brain with reduced volume due to restriction side by side with a healthy brain. “It’s important for us [clinicians] to realize when we’re working with a malnourished, underweight patient that there’s no amount of CBT (cognitive behavioral therapy) or DBT (dialectical behavioral therapy) or trauma work that’s really going to be effective unless that person’s brain is regrown first. So, first and foremost, food is medicine.”

Left: Normal control. Right: Patient with anorexia nervosa. (Image courtesy of Dr. Kim Dennis and SunCloud Health.)

Sometimes patients ask me to differentiate how my role, as a dietitian, differs from the roles played by other practitioners on their treatment team, namely their therapist. Oftentimes, I explain that eating disorders are mental illnesses that get played out through food. My role is to provide nutritional support during the early stages of recovery and then to help someone form a new and healthier relationship with food as the eating disorder recedes, but the bulk of the recovery happens in the therapist’s office.

For the reasons that Dr. Bermudez and Dr. Dennis explained, the brain cannot rebuild without weight restoration, and without an appropriately functioning brain, therapy – and therefore eating disorder recovery – becomes that much more of an uphill battle.

Privilege

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We welcome questions, feedback, and constructive criticism from our patients and readers, even if their opinions differ from ours, so long as the comments we receive are respectful. In response to a blog I wrote a few months ago discussing the intersection of nutrition and politics, one reader sent me the following message.

“I believe people’s passions for their careers should be evident. When someone comes through your door, they are seeking you out for your nutrition knowledge. You are brilliant at your job. The appointment is a give and take of information. However, I believe that people’s passions for politics should be kept private unless all parties have mutually agreed to share their views. Our views are slanted by all we know. As a former educator, we used to feel it was our job and it was our responsibility to try to remove our personal view from the workplace.”

Let me go through her points and respond to them one at a time.

“I believe people’s passions for their careers should be evident. When someone comes through your door, they are seeking you out for your nutrition knowledge.”

People seek out dietitians for all sorts of reasons. One person may have high cholesterol and hopes of lowering it via medical nutrition therapy, while someone else might have a history of chronic dieting and envisions building a healthier and more peaceful relationship with food. Some patients stop there, limiting their search for a dietitian to such criteria as perceived knowledge regarding a specific concern, as well as logistical factors, such as geographic location, ease of transportation to and from the office, insurance coverage, and appointment availability.

However, other patients have concerns that extend far beyond such basics. They want to know the person with whom they will potentially be working with and therefore desire some self disclosure on the dietitian’s part. Beyond that, many people value and are seeking a safe space for themselves. They want to know if their prospective dietitian will judge them for their size or behaviors, for example, or if the dietitian holds views on gender identity, ethnicity, religion, sexual orientation, skin color, nation of origin, or physical ability that hinder their ability to provide quality patient care. Sure, nutrition knowledge matters, our reader got that right, but she neglected to consider other factors of importance in a counseling relationship.

“You are brilliant at your job. The appointment is a give and take of information. However, I believe that people’s passions for politics should be kept private unless all parties have mutually agreed to share their views.”

The aforementioned individuals who are searching for a safe space for nutrition counseling need to know that we offer one. Furthermore, people sometimes ask us where we stand on societal issues and what actions are we taking to be a positive force in the world. They want to know what we are doing to combat weight stigma, for example, or to defend their health insurance coverage. Last fall, when we announced that we were donating 100% of the co-pays we collected between Thanksgiving and New Year’s to the Southern Poverty Law Center – an organization that fights hate and teaches tolerance – one ex-patient messaged me out of the blue to voice his displeasure while the rest of the feedback we received was positive.

Our practice’s philosophy is reflected in how we do our work – for example, we believe in collaboration and equality with our patients, which is why I like the symbolism of the round table in my office – and said philosophy also includes that we offer individualized nutrition counseling because we know that what works best for one person might not work so well for someone else. With that in mind, time spent in appointments belongs to my patients and I do not force political discussions on anyone, nor do I initiate them. If someone wants to focus on which fruits are highest in soluble fiber or some other superficial topic of hard science, no problem, fine by me, but my very next patient might be questioning what the point of working on their nutrition even is when they fear being murdered in a hate crime, having their health insurance stripped away, losing a loved one to deportation, etc. so I have to be malleable enough to respond to whatever feels most pressing to the person sitting with me at a given point in time.

“Our views are slanted by all we know.”

Exactly. With that in mind, I respectfully suggest that our reader reconsider the rest of her argument. Politics may have no place in nutrition counseling based on her world view and life experiences, but other people feel quite differently based on their own roads traveled.

“As a former educator, we used to feel it was our job and it was our responsibility to try to remove our personal view from the workplace.”

Just because I was a student does not mean I am an expert in education, but in my layman’s view I can envision issues with educators inserting their own political beliefs into their work. However, I question the parallel between that and nutrition counseling.

Teachers grade their students, sometimes write them recommendations, and are typically called by honorifics such as mister. Given a teacher’s position of power over their students, I can imagine that issues might arise if they reveal their own political leanings. Some of our patients, particularly children and adolescents, may expect a similar power dynamic when they first come to our practice, but we quickly dismantle that and emphasize that we are all on the same plane. We preach equality and collaboration, and nobody ever calls me Mr. Soolman twice.

Public education systems are taxpayer-funded institutions and my layman’s understanding is that they are supposed to accommodate the masses. If a teacher’s political discussion negatively affects the experience of a child who has every right to be there, I can imagine how that would be a problem, especially if said child does not want to or has no means to seek an education anywhere else. As a similar example, consider emergency room doctors who refused to issue the morning-after pill because doing so conflicted with their own beliefs. There was no room for such convictions in a hospital that is supposed to serve everyone, especially when time was of the essence and finding another clinic in short order might have been impractical or impossible.

Soolman Nutrition and Wellness, however, is a private practice, not a public institution, and patients have the choice whether to work with us or not. Sticking with the education theme, perhaps the best comparison would be that of a private school. If a Catholic high school wants to make daily prayer a way of life and take students on a field trip to Washington DC to participate in a pro-life march, so be it; those students and their families knew what they were getting themselves into when they choose to enroll there. If a family desires a more secular education, they can pursue enrollment at another private school or utilize the public school system to which they are entitled.

The reality is that while some people get irked by the occasional mention of politics in our blogs or e-newsletters, others feel comforted by those same inclusions. To feign political neutrality or to sidestep the topic entirely is still in itself to proclaim a stance and we would have to face the ramifications of our silence. We appreciate everybody who comes to our practice, but we cannot be everything to everyone; if we must turn off the privileged in order to welcome the vulnerable, we would rather do that than the opposite.

Carbs

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One of the quotes most pertinent to my work as a dietitian actually comes from a religion professor, Alan Levinovitz, who has taken to writing about nutrition in recent years because of the intersectionality of spirituality and food. He 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.”

In other words, good/bad food dichotomies offer comfort even if they are based more on theology than science, but why are carbohydrates often demonized? After all, given that the dietary reference intakes call for 45% to 65% of our total energy intake to come from carbohydrates, these macronutrients cannot really be that evil, can they?

First, remember the crosshairs of nutrition scapegoating are fickle and used to point elsewhere, such as fat in the 1980s and gluten more recently. These days, the most common reason I hear why people look down on carbohydrates as opposed to other foods is the perceived association between carbohydrate intake and weight change. Someone cuts his carbs, sees himself quickly drop weight, and therefore believes that carbohydrate elimination or reduction is the key to weight loss. Similarly, the weight regain that occurs with reintroduction of carbohydrates reinforces the notion that carbs are problematic.

Such conclusions, which are understandable if based solely on observation and experience, do not take into account the physiology of what actually happens within the body. We store carbohydrates in the form of glycogen in our liver and muscles so we have fuel for various processes, including physical activity. On a chemical level, water is bound up with the glycogen. Therefore, when someone reduces his carbohydrate intake and quickly drops weight, what he is really losing is water weight, not fat mass, as his glycogen stores decrease. Similarly, when he reintroduces carbohydrates, he rebuilds his glycogen stores and the water that gets packaged with it, and he consequently regains weight.

Furthermore, carbohydrate reduction can trigger a downward spiral. Because our bodies are adept at telling us when we are in need of a nutrient (For example, putting aside extraneous circumstances, we feel thirsty when we are dehydrated, and the action of drinking becomes less pleasurable as we rehydrate.), when we cut our carbs, we in turn feel an increased drive to consume them. If and when we finally eat them again, we are likely to overconsume, partly due to the body making up for the deficit and partly as a natural reaction to restriction. This overconsumption, especially if weight regain accompanies it, reinforces the preconceived notion that carbohydrates are problematic. Sometimes people even go so far as to believe they have an “addiction” to carbohydrates or specifically sugar. Thus, they cut carbs again and the cycle continues. This is a form of paradigm blindness in that some people do not realize that their presumed solution actually exacerbates the problem, so they keep adding more of the supposed solution to the ever-worsening issue.

Even if someone does manage to sustain long-term carbohydrate reduction, such behavior comes with risks. For example, fiber, which is important for cardiovascular health, energy stability, and bowel function regularity, naturally occurs in high-carbohydrate foods, such as legumes, vegetables, and whole grains. Therefore, reducing or eliminating these foods makes achieving adequate fiber intake a challenge. Carbohydrates are the brain’s primary source of energy, so not taking in enough of them risks concentration lapses, mental fogginess, and malaise.

During physical activity, our bodies rely on carbohydrates as the primary fuel source. As an endurance athlete, I have experienced the fallout from inadequate carbohydrate intake firsthand. Only twice in my life have I failed to complete a long-distance bicycle ride that I began: the first was when I fell off my bike and fractured my spine, and the other was a few years later while I was experimenting with a low-carb diet. During the latter ride, I became so fatigued and dizzy that I could not continue and had to have someone drive me home.

If carbohydrate reduction is not the key to good nutrition, what is? Well, the answer is complicated and not easily distilled into a soundbite. Health is both complex and multifaceted, and no two individuals are likely to define it in exactly the same way. Therefore, how we approach it from the perspective of nutrition has to be individualized as well. Speaking generally though, we suggest doing away with good/bad food dichotomies, which are more harmful than helpful, and instead placing all foods on a level playing field of morality. Rather than letting issues of guilt and virtue steer your eating, let your body’s internal cues be your compass. When you do that, you just may find that your carbohydrate intake falls within the aforementioned dietary reference intake range. Lord have mercy.

“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.