He Said, She Said: MEDA Conference Takeaways

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He Said

Today’s society is talking more and more about the idea of privilege. We often hear about white privilege, male privilege, and straight privilege, but people less commonly discuss another form that directly impacts our nutrition work: thin privilege.

My thin privilege became obvious to me four years ago when I went to the doctor about back problems. In early 2016, I wrote a blog reflecting on how different my healthcare experience was than that of many of my larger patients who go to their doctors about similar woes. Not only did I receive evidence-based medicine instead of a directive to lose weight, but some of my doctors even made assumptions (incorrect assumptions, at that) about my diet based on my size. That is thin privilege.

While I was already aware of some aspects of my privilege, the most powerful talk that I attended at the Multi-Service Eating Disorders Association (MEDA) national conference helped me to understand that my thin privilege includes elements I had never before considered. Caitlin Martin-Wagar, an eating disorder clinician and doctoral student in counseling psychology, gave a presentation in which she listed several examples of thin privilege, some of which you may not have previously considered either:

  • Chairs and airplane seats fit thin bodies.
  • Thin bodies are represented in all forms of media.
  • Thin people are never the punchline in sitcoms because of their body size.
  • When thin people go to the doctor, their health concerns are generally taken more seriously.
  • Thin people can buy dolls of similar build for their children.
  • Thinness connotes good morals and positive characteristics.
  • Thin people have an easier time shopping for clothing.
  • Thin people do not have to represent all people of their size.
  • In comparison to larger individuals, thin people receive less unsolicited health/dietary advice or veiled concerns about their health.
  • Employers pay thin people more.
  • Thin people face less scrutiny while eating in public.
  • As a thin person myself, I can write this blog without receiving accusations of being self-serving.

In order to escape weight stigma and in hopes of enjoying the same privileges as thin individuals, some people embark on weight loss endeavors that are most likely to make them heavier in the long run and worsen their health. If we are serious about wanting to help people improve their health, then we have to change our society so that people of all sizes enjoy the same privileges.

Ms. Martin-Wagar offered us professionals some tips regarding how we can combat weight bias within healthcare, but she also shared some ideas for how all of us can challenge thin privilege:

  • Read and learn about the relationship – and lack of relationship – between weight and health (which you can do on our Weight Loss FAQ page).
  • Consider the barriers and challenges of living with a larger body size.
  • Learn from larger-bodied friends about their experiences.
  • Do not make comments about people’s body sizes, shapes, or weight.
  • Be aware of weight bias veiled as concern.
  • Call out injustices as you witness them.

We do not live in a zero-sum game in which treating larger people better means treating thinner people worse. Rather, we can and must work to establish a society in which thin privilege is no privilege at all, just the same rights and respect enjoyed equally by people of all sizes.

 

She Said

This year’s MEDA conference had a number of interesting and informative talks given by experts in the field of eating disorders (ED). Throughout the day, I was heartened to see that the ED treatment community is starting to embrace the principles of Health at Every Size® (HAES) and Size Acceptance. But despite this positive movement, unfortunately what stood out to me this year was that we still have a long way to go in the ED treatment community when it comes to helping those in larger bodies who are suffering from an ED.  

Ragen Chastain, the author of the blog “Dances With Fat” and renowned speaker and advocate for HAES and Size Acceptance, was the keynote speaker on the second day of the conference. Her talk centered on the idea that given the culture that we live in (i.e., one that is fatphobic, diet-minded, and generally not welcoming to people in larger bodies), those who are living in larger bodies and struggling with ED can find it nearly impossible to fully recover as everything in our society tells them that being thin is the most important thing. Ragen’s talk hit the nail on the head, and it was interesting to see many of my colleagues in the audience nodding their heads in agreement with her points. At the end, Ragen received a well-earned standing ovation, and it seemed like everyone in the room was on the same page.

Well, not everyone, it seems. During the Q&A session after her talk, Ragen received a question from one of the ED practitioners in the room. This woman started out by saying that she agreed with everything Ragen had just spoken about, but she had an anecdotal experience that made her question some of Ragen’s points. She went on to explain that her “morbidly obese” brother had struggled with his weight for years, and it had gotten to such a dire point that a number of years ago he had gastric bypass surgery. As a result of this surgery, she contended, her brother’s weight went down and all of his troubling health conditions cleared up almost instantly. She went on to say that while she knows that some gastric bypass patients regain the weight due to “cheating” on their prescribed diets, there are those who maintain their losses and “good health.”

This woman’s sentiments went over like a lead balloon, and there were audible gasps from the audience. Ever the consummate professional, Ragen adeptly navigated this uncomfortable situation. She explained that while there are always some outliers who do well with stomach amputation, there are many more who suffer from complications from the surgery, such as lifelong issues with malabsorption, deficiencies, future surgeries to correct structural problems resulting from the original surgery, and even death. In fact, Ragen went on to say that fatphobia is at the root of the weight loss surgery industry because the medical professionals who advocate for these surgeries view fat people as less valuable; that it is better to risk a fat person’s life by having them get the surgery than letting them stay fat. In other words, the weight loss surgery industry is essentially telling fat people that their lives are not as valuable as those of thin individuals and that it is better to be thin and sick or even dead rather than fat.

While I would hope that this woman was the only one at the conference who held positive beliefs around weight loss surgery, I am not foolish enough to think so. Yes, the ED treatment community is getting better about not pathologizing certain body sizes and understanding that EDs can occur in people of all body sizes. But the fact still remains that we all live in this toxic diet culture that constantly tells us that fat is undesirable and unhealthy, that the pursuit of weight loss by any means is admirable, and that thin bodies are superior to fat bodies.  When you have been marinating in this culture for your whole life, it can be hard to realize your own bias around fat people. My hope is that Ragen’s talk changed some minds that day at the MEDA conference and made people think more about how their own fatphobia contributes to diet culture and undermines recovery for patients with ED.

He Said, She Said: Good for who?

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He Said

Our society’s problematic relationship with food has many elements, one of which is that we make sweeping generalizations and place foods, ingredients, and nutrients into dichotomous groups: good vs. bad, healthy vs. unhealthy, sinful vs. virtuous. When we use language like “good for you” to describe a given food’s supposed impact on our health, who is the “you” to which statements refer? That answer makes all the difference.

Those charged with shaping nutrition policy are faced with an impossible task. They do their best to create guidelines for the general population, but their advice fails much of the group because the truth is that when it comes to nutrition, individualization is a necessity.

In contrast, I have the privilege and good fortune to be able to focus on only one person at a time: whomever is joining me at my counseling table at any given moment. Recent conversations with some of my patients reminded me of just how essential it is to customize nutrition guidance.

For example, one evening I had back-to-back patients, one of whom utilizes whole grain products to her advantage in helping her stabilize her blood sugar, while the other must temporarily avoid such high-fiber food because of his acute gastrointestinal condition. If I had made a sweeping statement about whole wheat bread being “good for you,” I would have failed at least one of them.

Another day, I had a patient who is working to increase his potassium intake for the purpose of improving his hypertension and another patient who has renal disease and is on a potassium restriction. So, is a high-potassium food like cantaloupe “good for you” or what?

A couple of weeks ago, a patient referred to Gatorade as “crap,” to which I neutrally responded by mentioning that I drink it during long marathon training runs. He continued to say that my situation is different than his, which was exactly the conclusion I hoped he would reach when I decided to disclose that a beverage with no redeeming qualities in his eyes actually works quite well for me.

My one-decade anniversary of becoming a registered dietitian is coming up this summer, and during all my years of practicing, I cannot remember two patients who ever came in with the exact same set of circumstances. In reality, our situations are always different, as each of us has a unique set of health concerns, preferences, histories, cultural norms, financial considerations, and all of the other factors that together shape one’s relationship with food.

Instead of dividing foods into dichotomous groups that reflect sweeping generalizations about what is “good for you” in reference to the general population, take a morally neutral and pragmatic approach built on individualization. Recognize that every food has a set of attributes – including taste, cost, availability, nutrient content, and preparation options, just to name a few factors in its profile – that makes it more or less advantageous depending on the circumstances. Remember, the very food that you believe is “bad for you” might be great for someone else.

 

She Said

One of the underlying themes I have found amongst nearly all of my eating disorder (ED) patients is the idea that their ED often started with the intention to become “healthier.” Whether “healthier” meant to lose weight, improve certain biomarkers, or just feel better, these individuals embarked on a restrictive food mission, omitting certain “bad” foods (mostly foods high in sugar and fat) and replacing said foods with “good” foods (mostly vegetables and protein). As harmless as these initial intentions seem at first glance, for someone with ED, they often unravel into something potentially life threatening. 

For my patients with anorexia nervosa, this fixation on “good” and “bad” foods can result in a dangerously low body weight. In addition to extremely low weight, the lack of calories literally starves every organ of the body, including the heart and the brain. Brain scans of healthy control brains versus brains of patients with anorexia show that anorexia literally shrinks the brain. As such, these individuals undergo profound brain changes that lead to decrease in cognitive functioning (due to slowed neuronal growth), depressive symptoms (due to lower levels of neurotransmitters), and a reduction in affect displayed (due to shrinkage of the frontal lobe). What is really insidious about EDs is that they start off in the brain as mental illness and eventually lead to damaging the same brain by means of malnutrition. It is a vicious cycle.

The only way to break this cycle is by refeeding (in addition to therapeutic help and perhaps medication). In this initial stage of recovery, it is imperative that the patient take in enough calories to restore his or her body weight to their healthy weight range. In fact, it is almost impossible for therapeutic measures and medications to really help these patients until their brains are at least back to functioning levels. Many of my patients with severe anorexia struggle with brain fog, have trouble formulating thoughts, and cannot communicate clearly due to brain deficits, and this makes therapy not nearly as effective as when the brain is at least functioning at baseline.

The tricky part about refeeding is that many of the “bad” foods that these patients have been avoiding are, in fact, the same foods that will help them to restore weight most easily. These high carbohydrate/high fat foods are integral to getting these patients to their healthy weight ranges, as they usually have higher concentrations of calories than low carbohydrate/low fat foods. As such, these foods pack a much bigger punch, providing more calories in a smaller amount, making it easier for patients to get what they need while lessening the gastric overload.

Many of my underweight patients who need to weight restore will ask me if they can just eat more of the “good” foods to help them gain the weight back. Aside from heart-healthy nuts, avocados, and nut butters, most of the “good” foods fall into the low carbohydrate/low fat group that provides very few calories for the same volume. In other words, these noncalorically dense foods pack less of a punch, meaning that one would need to eat a much larger volume of these foods to get the same amount of calories that are in calorically dense foods. In order for someone to regain weight, eating large amounts of vegetables and protein is not going to get them to their goal as their stomach will simply prevent them from consuming enough.

What is “healthiest” for these patients is to consume calorie-dense foods and avoid those foods that take up more volume but do not provide the necessary calories. Thus, for the sake of example, a pint of Ben & Jerry’s ice cream is a better choice than a salad for someone who needs to regain weight. We have all been taught that certain foods are always “bad” in every context (ice cream, fried foods, sweets), but the example above shows that it is not so cut and dried. Is a pint of Ben & Jerry’s the “healthiest” choice for someone with high cholesterol? Possibly not. But for someone with anorexia who needs to gain weight, it is healthier. 

In other words, “healthy” is a very subjective term when it comes to nutrition. One size does not fit all as everyone has different health goals and medical conditions. While whole wheat bread might be the better choice for someone who suffers from chronic constipation, it would wreak havoc on someone with diverticulitis and should be avoided.   The “good food/bad food” dichotomy is problematic because it does not take the individual into account. The way we talk about food in our society needs to change.

He Said, She Said: Weight Stigma

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He Said

Examples of weight stigma are prevalent and run the gamut: clothing and airline seats designed for smaller bodies, cyber bullying, verbal insults, physical attacks, and social exclusion. Even our own government has declared war on fat people. Unfortunately, weight stigma also infiltrates and inflicts harm in a space that is supposed to promote health: the doctor’s office.

Obesity is associated with a number of health woes, and, clinically, your doctor probably finds more problems in heavier patients than in thinner ones. Consequently, your doctor might recommend weight loss as a supposed path to better health. On the surface, such well-intentioned advice sounds reasonable, but it is problematic for a multitude of reasons.

Correlation does not equal causation. In other words, just because two factors tend to occur together does not mean that one necessarily causes the other. The diseases blamed on obesity could be due to other factors that tend to co-occur with increased body weight.

In other words, the causal factor might not be your weight, but rather one or a multitude of other factors associated with your weight.

Your doctor may have heard of the National Weight Control Registry, a database of “over 10,000 individuals who have lost significant amounts of weight and kept it off for long periods of time.” Some doctors believe that if their patients adopt the behaviors exhibited by people in the Registry, their patients are likely to achieve similar weight loss.

Unfortunately, presenting these behaviors as the key to long-term weight loss makes little sense when so many other people perform the same actions without achieving similar outcomes. The lottery crowns new millionaires every single day, and a quick study of the winners reveals that a behavior common to all of them is that they bought tickets, but that does not mean your financial advisor is giving you sound, ethical, evidence-based advice if he suggests you take your life savings and invest in Powerball.

Even if a causal relationship exists between body weight and your medical condition, endeavoring to lose weight is still not the answer. In light of the research showing the prevalence of weight regain that often surpasses baseline weight, we can only assume that the condition you are trying to improve by losing weight would actually worsen in the most likely scenario that you end up heavier than you are now.

For these reasons, many healthcare providers – including us – believe it is unethical to recommend weight loss to patients as a path to better health.

Weight stigma in healthcare can also negatively impact thinner individuals. For example, binge eating disorder is a condition stereotypically associated with larger people, but the reality is that it can affect people of all sizes. Doctors may dismiss or overlook red flags in individuals who do not look the part. Furthermore, just as doctors sometimes make incorrect assumptions about the behaviors of larger individuals, doctors may assume that thinner patients are leading healthier lifestyles than they really are.

On a personal note, as someone with a relatively thin body, I have certainly had my share of doctors make assumptions about my eating behaviors – without asking me a single question about my feeding habits or my relationship with food – because of my body. Typically, their assessment is along the lines of, “Clearly, your nutrition is fine,” as they glance down at me. How often do you think people labeled “overweight” or “obese” hear such a sentiment from their doctors?

In hopes of freeing themselves from weight stigma, some people resolve to change their body to a size and shape that our society deems more acceptable. While we firmly support a patient’s right to choose for themselves the approach to healthcare that feels most appropriate for them at any given time, we also believe in disclosure and informed consent so patients can make educated decisions. After knowing the facts regarding the failures of weight loss endeavors, you may still decide to travel that road. Know, however, that you have a choice. For more information regarding how to tackle weight stigma and pursue better health in a weight-neutral fashion, please see our Weight Loss FAQ.

 

She Said

Weight stigma. People living in larger bodies are often treated as less than and discriminated against in many different contexts. This goes double for those people of size who are also people of color, LGBT, and/or disabled. From being body shamed at the doctor’s office to earning less money than their thinner counterparts to being ridiculed by the media and told they are a problem that is to be solved, fat people have it tough in our society.

While it is neither unexpected nor surprising when weight stigma is exhibited in all of the above situations, it is simply mind-boggling how it is displayed in certain “woke” spaces. Take, for instance, the eating disorder (ED) treatment community. Here is a group of professionals whose job is to help individuals heal their relationships with food and their bodies. One would think that this help should be offered to ED patients in all different body sizes. Unfortunately, this is rarely the case.

I have a number of patients who clearly exhibit ED behaviors, such as restriction, bingeing and purging, or excessive exercise, yet their higher weight precludes them from meeting the criteria for an ED like anorexia nervosa or bulimia nervosa. Instead, these patients fall into the catchall category of “ED NOS” (eating disorder not otherwise specified), also known as “OSFED” (otherwise specified feeding and eating disorders). This means that even if someone is heavily restricting their intake, no longer menstruating, and severely malnourished, but their BMI falls in the “normal,” “overweight,” or “obese” categories, they are not seen as “sick” as those who are “underweight.”

Never is this more clear than in inpatient or residential treatment for EDs. While the emaciated patients are refed aggressively to help them regain weight, those in larger bodies are often fed just enough to sustain them because it is assumed that they do not need to regain any weight. In some cases, I have heard of ED facilities actually trying to help the larger ED patients lose weight, as “clearly they could stand to lose a few pounds.”

This difference in how patients are treated is not only disturbing, it is also quite damaging to ED patients who live in larger bodies. Many of my larger patients have actually become more symptomatic after being discharged from treatment because they felt they needed to be even “sicker” to receive adequate help. I specifically remember one such patient who, even though she was eating only 200 calories per day and was exercising for hours on end,would only get to stay at a program for a couple of weeks and then be discharged for outpatient care as her weight was not concerning enough.

This has got to stop. EDs are found in people with all different body types. Just because someone does not appear to be emaciated does not mean that he or she is not suffering from a debilitating ED. The ED treatment community needs to start treating ED patients who are living in larger bodies with the same care and concern as those living in smaller bodies. Hopefully, someday there will be an end to weight stigma in ED treatment as well as in other areas of our society.

Crime and Punishment

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Michael Felger, a sports radio host in Boston, received national attention last week for his extended rant in reaction to the death of Roy Halladay, the former pitcher who was killed when the plane he was piloting crashed into the Gulf of Mexico.

“It just sort of angers me,” Felger said. “You care that little about your life? About the life of your family? Your little joyride is that important to you that you’re going to risk just dying. You’re a multimillionaire with a loving family, and to you, you have to go get that thing where you can dive-bomb from 100 feet to five above the water with your single-engine plane with your hand out the window. ‘Wheee! Wheee! Yeah, man, look at the G-force on this! I’m Maverick! Pew pew pew! Yeah, man, look at this, this is so cool.’ And you die! Splat! If I die helicopter skiing, you have the right to do the exact same thing I’m doing to Roy Halladay. He got what he deserved.’’

Felger took it too far and he knows it. “In a nutshell, I would say that I feel bad about what happened on a lot of levels,” he said the next day in his on-air apology. “I feel bad about what I said and how I conducted myself. To say it was over the top and insensitive is really stating the obvious.”

However, Felger limited his contrition to the poor timing and distasteful nature in which he communicated his points, but he held firm to his core arguments. “I believe what I believe,” he noted, a sentiment to which he returned over the course of the four-hour show to emphasize that he was not apologizing for his feelings, but only for how he conveyed them.

That is unfortunate, for as much credit as I give Felger for taking responsibility for his tone and tactlessness, going out of his way to double down on his stated beliefs suggests a failure to understand the inherent dangers of condemning someone else for making a choice or engaging in an activity that subjectively feels too risky to the person passing judgment.

Stunt flying, as Halladay was reportedly doing at the time of his crash, is inherently dangerous, but all choices exist on a risk continuum that never quite reaches zero. Every single one of us makes decisions on a daily basis that someone else might deem too risky, but we weigh the pros and cons and ultimately take the risks that in balance feel worth it. Some of us cross busy streets, gather in crowds, work stressful jobs, play contact sports, get behind the wheel, mount bicycles, undergo elective medical procedures, attend protests, testify against violent defendants, and yes, some of us stunt fly. We all draw a line somewhere regarding what we, personally, feel is too risky, but who is to say that our placement is any more right or wrong than where someone else draws their own?

For another example of a choice that could be considered too risky, Felger need not look any farther than the chair next to him. His co-host, Tony Massarotti, elected to pursue a weight-loss treatment plan at a local diet center and pitches the program via radio spots every afternoon. Hopefully he knew going into it that he is unlikely to sustain his lower weight and that weight cycling, regardless of one’s baseline weight, is associated with a higher overall death rate and twice the normal risk of dying from heart disease.

Hopefully, nobody will claim, “He got what he deserved,” if Massarotti dies of a heart attack, yet some do just that. A fervent raw vegan that I used to run against once suggested that we should treat omnivores who die of myocardial infarctions as suicide victims because, in his eyes, their deaths were self-induced by years of consuming cooked foods and animal products. They are shooting themselves, he explained metaphorically, they are just pulling the trigger really, really slowly.

To suggest that people who follow a diet other than his own are killing themselves is to pass quite a judgment, one that is particularly curious since other restrictive diets have their own staunch followers who similarly believe that raw vegans are bringing about their own demise. Ours is the path to salvation, extremists believe, while others are deservedly damned for worshiping another dietary God.

Across the street from the radio station, a related story of crime and punishment is apparently unfolding at New Balance, where, according to someone I know who works there, the company has started measuring employee body mass index (BMI) annually and now charges fat workers more for health insurance than their leaner colleagues.

Perhaps New Balance’s intent is to encourage employee engagement in behaviors subjectively considered healthy and/or to financially demand more of the individuals who are seen as the greatest burden on the healthcare system. In either case, the company is erroneously conflating behaviors, health, and anthropometrics. To charge heavier people more for health insurance is to issue a stiff sentence after an unjust conviction.

The policy is a clear case of discrimination that exacerbates weight stigma and risks worsening the health of fat people, in part by encouraging them to pursue weight loss, sometimes by very dangerous means, in order to be treated, both financially and otherwise, like everyone else. Such a policy also negatively impacts thinner people. One of my patients, the child of a New Balance employee, is working to recover from a restrictive eating disorder and exercise bulimia that were triggered by – get this – a fear of becoming fat. Given how heavier people are treated, including by New Balance, who can blame this kid for wanting to avoid such torment?

The accumulation of insurance payouts for this patient to attend regular and ongoing appointments with me and the rest of the treatment team is certainly expensive. With this child representing just one small twig on the tree that survives on the light that is New Balance’s insurance coverage, perhaps this reprehensible policy will increase, not decrease, the totality of the company’s financial healthcare burden. If that possibility comes to fruition, I will borrow a line from Felger and decree:

They got what they deserved.

You (Still) Are Not Tom Brady

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Yesterday evening, the New England Patriots curiously traded away Jimmy Garoppolo, their backup quarterback and the heir apparent to 40-year-old incumbent Tom Brady. As fans attempted to make sense of the move, media members did the same. Albert Breer tweeted, “Not to be overlooked: Patriots pushing their chips in on Tom Brady playing well into his 40s.” A few hours later, John Tomase published a column in which he questioned the move, noting, “. . . no quarterback in history has managed to avoid falling off a cliff at age 41.”

Tomase’s point is spot on. Remember, Warren Moon was 38 years old at the beginning of his 1995 season that concluded with a trip to the Pro Bowl and then returned to the all-star game two years later, but during the 1998 season, which he began at 41 years old, his quarterback rating, games played, and touchdown-to-interception ratio all fell off before he ultimately finished his career as a backup in 2000.

Brett Favre turned 40 early in the 2009 season, which was arguably one of his best ever. His 107.2 quarterback rating was higher than in any other season of his career as he took his team to the conference championship game. However, he followed that up with a miserable 2010 season during which he posted a 69.9 quarterback rating, the lowest of his career as a starter, and come 2011 he was out of the league.

By trading away the highly-touted Garoppolo, the Patriots presumably believe Brady will somehow avoid the same age-associated fate as every quarterback who has come before him. But why? Brady himself has his sights set on playing through the 2025 season, which he would conclude at age 48, and he seems to believe that his nutrition and lifestyle choices will play a large part in helping him get there.

In 2015, he told CBS Sports, “So much of what we talk about, Alex [That’s Alex Guerrero, the man Brady describes as his “spiritual guide, counselor, pal, nutrition adviser, trainer, massage therapist, and family member,” the same Alex Guerrero who, according to CBS Sports, once lied about being a doctor and at least twice was investigated by the Federal Trade Commission for making claims about his products without medical evidence.] and I, is prevention. It’s probably a lot different than most of the Western medicine that is kind of in a way you — I’d say in professional sports, or in any sport in general, you kind of just play the game until you basically get hurt. Then you go to rehab and then you try to come back and you try to play your sport again. And I think so much for me and what we try to accomplish with what my regimen is, and what my methods are, and the things of my belief system, is trying to do things proactively so that you can avoid getting injured.”

Brady seems to view nutrition as a key component of his and Guerrero’s prevention strategy. “When you think about nutritional supplements you think about other types of training methods and training techniques. I think that’s a great thing. I think when you talk about a green supplement — it’s vegetables. It’s eating better. That’s not the way our food system in America is set up. It’s very different. They have a food pyramid. I disagree with that. I disagree with a lot of things that people tell you to do.”

Brady calls attention to his unusual dietary beliefs and habits, not just through interviews, but also his book and a “sports therapy center” at Patriot Place. Even I have written about Brady’s dietary stances, although not necessarily in a flattering way. Early last year, I picked apart an interview with Allen Campbell, Brady’s personal chef, and while I regret the snarky tone with which I wrote (as I now realize that such an attitude can repel the very people who need to hear the message the most) I stand by my assessment.

My concern is not for Brady, as he is an adult who can do whatever he believes to be in his own best interests, regardless of the factual accuracy of his stance. As a Patriots fan, I am disheartened that the team seems to have bought into Brady’s and Guererro’s hype, and I have a feeling that regret for having traded away Garoppolo is right around the corner for those who made the move.

By far though, my main concern is for the ultimate victims of the trickle-down effect, the adults and children alike who see Garoppolo’s trade as an indicator of Brady’s expected longevity and therefore an indirect endorsement of his nutrition beliefs, and who consequently change their own eating patterns in a negative way as a result. To mitigate the fallout, we must view Brady’s nutrition behaviors under the light of ordinary life rather than the glitz of professional athletics and call them what they really are: disordered eating.

In time, we will know whether Brady was able to stay in the league and maintain a high level of play at an age by which every quarterback before him, including Moon and Farve, had experienced significant decline. Maybe some people similarly believed those latter two athletes had the secrets to defying age until time proved them wrong.

Certainly, Brady has the right to opt for whatever lifestyle behaviors he believes will keep him in the game for years to come, but remember that professional athletics are an entirely different ballgame than the life most of us face. To quote myself from a piece I wrote on Brady nearly three years ago, “Real life exists in grays, so building healthy relationships with food means both listening to our bodies and being flexible to allow for the complexities and variables that come our way. A professional athlete may have incentive to sacrifice such a relationship and rely instead on external rules because the here-and-now upside is so great, but the rest of us are better off learning a lesson from the 99.92% of high school football players who will never play in the National Football League. In other words, think long and hard before deciding to sacrifice for the here and now, and instead focus on life’s big picture.”

Fitness Trackers

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He Said

As recently as six or seven years ago, I was still estimating the length of my running routes by driving them and reading the odometer. After my runs, I used a program on my graphing calculator that computed my pace per mile based on my time and distance covered. Archaic, I know. These days, I use a GPS watch that gives me all of these numbers and also tells me my speed in real time. The data are tremendously helpful as I train for races, and rarely do I leave the house for a run without my GPS watch.

As helpful as GPS watches and other fitness trackers can be, they also have serious drawbacks. While it is normal to be excited after a great run or disappointed after one that does not go as we had hoped, some people put a concerning level of emphasis on their exercise performance. For example, someone may push through injury or illness in order to attain a certain reading on their device when the healthier play would have been to stop earlier or take a rest day.

Issues with exercise can bleed into food. For example, someone who feels they did not run far enough or fast enough, take enough steps, or burn enough calories might punish themselves by bingeing or restricting their food intake. Someone else might overeat or allow themselves certain foods that are normally restricted after a particularly pleasing exercise session. Some people restrict either way, feeling they do not deserve to eat normally if their exercise was not up to par, while also not wanting to “undo” a good exercise performance by eating. All of these examples and other similar behaviors are red flags of an unhealthy relationship with food and physical activity exacerbated by usage of a fitness tracker.

Furthermore, we must remember that even the best fitness trackers have flaws in their technology. For example, back when Joanne wore a Fitbit (discussed below), it never registered steps she took in the supermarket if her hands were on the grocery cart. When I finished the Newport Marathon earlier this month, my GPS watch reported that I had covered 26.6 miles, which was curious since marathons are 26.2 miles long. As I discussed a couple of years ago, estimates of calories burned can also be wildly inaccurate.

Given the limitations of these devices and the trouble people can find themselves in if the numbers are carrying an unhealthy level of importance in their lives, we best candidly ask ourselves if the pros of fitness trackers really outweigh their cons.

 

She Said

Nearly everywhere you look nowadays, you will see people wearing some sort of activity tracker. Whether it’s a Fitbit, an Apple watch, or a Garmin device, it seems that lots of people are concerned with monitoring their movement from day to day. For a few years (a few years ago), even I wore a Fitbit, and I found myself becoming obsessed with the number of steps I took each day. I remember needing to meet or exceed my goal of 10,000 daily steps, regardless of how I felt physically or mentally. It became such a constant in my life that whenever I took steps without the device, I felt like those steps didn’t really count. If I forgot to wear my Fitbit before a walk or run, the steps I took were automatically negated. Throughout my day, I would often look to my Fitbit to see if I had been “good” that day, to see if I had achieved my goals. It was an obsession!

When I found Health at Every Size® (HAES), something changed for me in regards to physical activity. One of the tenets of HAES is engaging in enjoyable movement that feels good to one’s body. I like to call this “intuitive exercise” (I’m sure that someone else has coined this phrase, but I’m not sure to whom to attribute it!). In my mind, intuitive exercise is engaging in physical activities that one enjoys, i.e., not using physical activity as a way to punish one’s body. Intuitive exercise comes from an internal desire to feel good in one’s body, to participate in sport or activity that nourishes one and makes one feel alive. Intuitive exercise is not prescriptive or punitive – it’s purely for the joy of movement. 

Once I figured out what intuitive exercise was, I found that wearing my Fitbit was not really compatible with HAES. For a while, I had been letting a little wristband tell me how much I should move – pretty much the exact antithesis to intuitive exercise! In a way, I liken it to when people feel they need a diet or set of food rules to follow in order to be healthy. Time and time again, we have heard that diets fail 95% of the time, but for some reason, we are convinced that using a set of external guidelines will lead us to diet salvation. But, of course, we know that this isn’t the case, that eating intuitively and trusting our body is truly the best way to achieve a healthier relationship with food and our body.

A number of my patients struggling with eating disorders (ED) wear activity trackers, and I find this to be a particularly troubling trend. Those patients who never had issues with exercise before now are obsessed with the numbers on their Fitbits. Most of the activity trackers also track the number of calories one burns. Even though these calorie estimates are often bogus and inaccurate, people with ED can become fixated on them. Complicating matters, many of these activity trackers can also double as a “smart watch,” meaning that the wearer can use it to browse the internet and send and receive texts, emails, and phone calls. So even if someone just wanted a device to do these “smart” tasks, they would be unable to avoid the activity tracking aspect.

In general, I discourage all of my patients from using these activity monitors, even those without an ED. In my opinion, while some people may be able to use these devices as a motivating tool (i.e., encouraging them to get more physical activity into their day), the majority of people who wear them become obsessive. Those individuals struggling with ED are particularly at risk of developing (or worsening) excessive exercise behaviors, as these devices become tools for ED.  Unless one can deactivate the step counter and calorie tracker from a device, I feel these trackers can be incredibly triggering for those struggling with ED or disordered eating.  

Pineapple

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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.