The “T” Word

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“You run into that more than I do. All of my patients are already in therapy.”

That is how Joanne responded when I suggested that she write a feature about the challenge of helping resistant patients in need of therapy to agree to go. Apparently, the responsibility of writing about the topic then falls on me, and appropriately so, I suppose, for I do run into this issue quite often on my side of our practice.

Joanne rarely runs into this dilemma because she focuses exclusively on eating disorders, and by the time a patient makes their way to her, the importance of a complete treatment team – a dietitian, a physician, and yes, a therapist – has usually been explained and emphasized to them at some point already.

In contrast, while eating disorders are similarly my area of specialization, I also help people with other conditions, such as high cholesterol and hypertension. As such, I tend to attract patients who view – or want to view – their challenges as superficial food issues even if it quickly becomes apparent to me that something deeper is at play.

That brings us to a critical juncture in our work and often a difficult conversation. How do we emphasize the importance of therapy while remaining sensitive to the reality that we live in a society that stigmatizes mental health issues?

Well, we do just that. We talk about the upsides of therapy as well as the patient’s thoughts, questions, and concerns, including any hesitations they might have. Oftentimes we also talk about the stigma because I think it is important to bring out into the open the reality that a therapy referral comes with a connotation that would not arise if I were suggesting someone meet with pretty much any other kind of specialist.

Sometimes patients are hesitant to disclose their true reasons for not wanting to go to therapy, or maybe they have trouble putting their fingers on what their reasons are, but they know they do not want to go. “It is not worth the time,” “I do not hate myself,” and “I have friends I can talk to” are some of the superficial reasons patients have told me. Time, trust, and continued conversation are sometimes necessary for us to get to the point of having a candid discussion about whatever their hesitations really are.

A common sentiment I hear is, “I think I want to start with just a dietitian.” Earlier in my career, I had a peer supervision leader who refused to work with a patient with an eating disorder unless they were also in therapy, a policy that I then adopted. Eating disorders are mental health issues that play out through eating behaviors, so while they affect nutrition, they are not directly nutrition issues. The dietitian’s roles are to provide nutrition support (if applicable) and to help the patient form a new and healthier relationship with food as the disorder recedes. However, because eating disorders are mental health issues, the bulk of the recovery does not happen with a dietitian, but rather with a therapist. Without this key member of the treatment team, the patient’s chances of recovery drop so dramatically that some dietitians, including my peer supervision leader, feel it is unethical to work with someone who refuses therapy.

In the last few years, as a result of conversations I have had with other colleagues, I have reversed course. The rationale is that if I terminate my work with a patient who refuses therapy, then they are left with nobody to help them, but if I continue working with them, then at least they have me in the meantime, and, hopefully, they will become more open to the idea of therapy as time goes on.

As dietitians continue to debate this issue, my own ambivalence oscillates from one side to the other and back again, and I have no idea what my policies will be in this regard down the road. What I do know, and what dietitians who specialize in treating eating disorders agree on, is that therapy is essential for recovery.

Therapy can also be immensely helpful for some patients without eating disorders, too. One of the most interesting aspects of nutrition work – but also one of its greatest challenges – is the wide array of factors that influence the decisions we make regarding what, when, and how much to eat. Many examples, such as low self-esteem or a poor relationship with a close family member, can significantly affect eating behaviors, yet are largely beyond my expertise to treat alone. The boundary of my scope of practice bleeds into that of mental health professionals, who can effectively address these deeper issues and free people up to form healthier relationships with food.

Questionable Measures

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Last month, one of my friends told me that his health insurance, Tufts Health Plan, offers Good Measures, a nutrition and exercise tracking website, for free to members like him. When I told him I had never heard of the site, he gave me his login information so I could check it out.

This piece you are reading is by no means a thorough critique of Good Measures, nor do I think a comprehensive evaluation is even necessary, for I have enough concerns from my limited exploration to know that I would not recommend this site to patients.

Having said that, to be fair, Good Measures does have some nice features. My friend, who is a software programmer and artist, was impressed by the site’s visual appeal and how user-friendly it is to navigate and input data. One feature that quickly caught my attention is that if it detects that a user’s intake of a particular nutrient is low, it will go through the person’s food logs and highlight the foods with high concentrations of the nutrient in question in order to show the user that they can increase their intake simply by consuming more of these foods they already eat. Good Measures also presents some new foods for the user’s consideration, which can help to inspire ideas.

My concerns about the website are less to do with its design or mechanics and more about the problematic messages it teaches about nutrition. Even though I do like how Good Measures helps to generate ideas for consuming more of a given nutrient, users are misled into believing that underconsumption is definitively a problem when in fact it might not be at all.

Someone can consume less of a particular nutrient than their estimated needs would call for and often be just fine, but Good Measures teaches quite the opposite by labeling such shortfalls as “under and it matters.” Implying that someone has to hit their target intakes every single day or risk malnutrition creates unnecessary stress and is ultimately misleading because that simply is not how our bodies work.

Deficiencies, which can often be detected through blood analyses, can develop over time if intake of a particular nutrient is chronically low, but they do not suddenly appear after a single day, or even a few days, of consuming below one’s estimated needs.

Part of having a healthy relationship with food is being flexible and varied in our eating. We will be hungrier and eat more on some days than others. Our intake of a particular nutrient could be quite high one day and quite low the next, and that is perfectly fine. In the big picture, our bodies get what they need even if each day is a bit different.

Getting down into the nitty-gritty, another problem I have with how Good Measures addresses issues of nutrient deficiencies and excesses is that it does not take absorption into account. Commonly, we think of putting food “in” our bodies when we eat it, but technically speaking, the food is not actually inside our systems until it has been digested and absorbed through the lining of our gastrointestinal tract.

Various factors influence the fraction of consumed nutrients that make their way into our bodies. Some of these factors are unique to us, such as our genetics and gut microbial populations, but examples of others include food sources and combinations. Good Measures could not possibly take the former into account, and it seems to make no attempt to factor in the latter either.

Consider iron and its two forms, heme and non-heme. Our bodies are quite poor at absorbing iron, but heme iron, which is found in animal flesh, is better absorbed than non-heme iron, which comes from plants. If I eat a piece of steak or a pile of beans with equal iron contents, my body will absorb more iron from the meat than from the legumes. Poor absorption of non-heme iron is why vegetarians are often advised to consume more iron than omnivores, but Good Measures does not seem to account for this. Taking in an iron-containing food with a source of vitamin C, such as a glass of orange juice or some red pepper slices, will improve iron absorption, but Good Measures does not seem to factor in this physiology either.

That such important nuance was overlooked does not surprise me, as my impression is that this website was purposely designed to be overly simplistic. Consider the Good Measures Index (GMI), the definition of which is, well, I will let the website’s help directory explain it.

In my opinion, one of the most significant problems in how our culture views food and nutrition is that we oversimplify and overgeneralize multifaceted issues to the point where our distillations teeter on the border of doing more harm than good, and sometimes they cross right over that line. Given how complex our bodies and our relationships with food are, the notion that our eating can be boiled down into a numeric value strikes me as dubious at best. 

Beyond that, while the GMI seems designed to suggest that there are no good/bad foods, its impact is quite the opposite. Using my friend’s Good Measures profile as a testing ground and various real-life binge incidents that patients have reported to me, I experimented to see how an evening of overconsumption would affect my friend’s GMI. The most severe of the three binge episodes that I tested was enough to plummet his day’s GMI from 94 all the way to zero, which is ridiculous on multiple fronts.

The binge foods that I used in the example, even if they were consumed in excess, provided an abundance of nutrients that the body would utilize to function. To suggest that a binge can negate everything that came before it is nonsense. Reducing the day’s GMI to zero tells the user that positive eating experiences that may have occurred earlier in the day can be undone, which is false and hearkens back to the problematic calories-in vs. calories-out model in which someone’s exercise bout can be viewed as cancelled out if they take in “too many” calories afterwards.

The GMI’s 0-100 scale is similar enough to academic grading to suggest that 100 is perfection, a target for which to strive, and that a score less than that is due to errors, like wrong answers on an exam. In reality, a 100 GMI could indicate that someone is too rigid and might be struggling with orthorexia. Even my friend, whose relationship with food strikes me as quite healthy, felt like his 94 GMI must indicate that he is doing something wrong and wondered out loud if he should be striving for 100. In my practice, I have seen so many eating disorders that were sparked when a high achiever with perfectionist tendencies applied these traits to their eating, and I can easily imagine the GMI furthering this problem.

Another area where Good Measures takes a complex topic and dumbs it down to useless numbers is weight control. Pursuing weight loss is dangerous and problematic for the reasons we discuss here, yet Good Measures acts as if it is just a matter of elementary school arithmetic. Input your age, gender, height, current weight, activity level, and desired weight, and it outputs “your personalized daily calorie goal.”

Earlier in my career, I also used algorithms like theirs to advise people on weight loss. In the long run, they do not work. The calories-in vs. calories-out energy balance paradigm is an oversimplification of the factors that influence weight regulation, which is mostly out of our control.

Consider atypical anorexia nervosa, a condition with all of the restrictive features of anorexia, but the patient is not medically “underweight” despite their severe malnutrition. In other words, atypical anorexia nervosa is, as some of our colleagues say, anorexia nervosa without the weight stigma. Good Measures and other nutrition and fitness trackers can present all the “success stories” they want, but the truth remains that sometimes – oftentimes – our bodies just do not lose weight in accordance with what simple math would predict.

At the other end of the spectrum, weight gain is no guarantee either despite Good Measures also suggesting that putting on mass is just a matter of taking in enough calories. One of my best friends is very thin and wanted to put on weight for aesthetic reasons. He has a PhD in physics, understands energy balance as well as anybody out there, and explained to me that all he has to do to gain weight is take in more calories than he expends. The human body is more complex than that, I cautioned him, but he insisted. Over the ensuing weeks, he increased his caloric intake, logged everything he ate, and tracked his weight on an Excel spreadsheet. One day, he emailed me his spreadsheet and a message saying, “WTF?” While he had gained a small amount of weight, his spreadsheet showed that his weight had leveled off and would no longer budge no matter how many calories he ate. Changing our weight in either direction is just not nearly as straightforward as Good Measures makes it seem.

Tufts Health Plan members who use Good Measures also receive at least one free telephone consult with a registered dietitian, so in fairness, it is possible that the professional on the other end of the line might help to clarify some of the website’s limitations and put the data into better context. However, the soonest appointment my friend could get for his initial consult will not take place until nearly two months after he started using Good Measures. If that is a typical wait time, that means users have approximately eight weeks to misinterpret and internalize whatever they glean from the site.

For nearly two months, people who have an active eating disorder, a history of one, or are at elevated risk for such a disorder are using a triggering tool that can start a downward spiral without first being informed of the risks. According to one estimate, 14.3% of males and 19.7% of females will experience an eating disorder by the age of 40, which loosely translates to one in six individuals overall. Given such high prevalence, Tufts Health Plan is negligent in offering Good Measures to its members without guarding against the harm it does to this segment of the population.

Despite having some nice features and an aesthetically pleasing design, Good Measures has fundamental issues that prevent me from recommending it to patients.

 

Privilege and Cowardice: A Chronology

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“You should have hit her. She’s black.”

It is 1989, and I am a sixth grader struggling to adjust to life at Pollard Middle School. We are in music class. Instead of practicing their piano parts, two boys are sexually assaulting one of our classmates, laughing as they repeatedly grab her breasts and pinch her buttocks despite her best efforts to swat their hands away.

When the brown-skinned girl sees me looking at her, she recoils and asks me if I am going to touch her, too. No, I would never, that is not at all who I am. But she does not know that. The fear on her face suggests that despite her young age, she has already learned to see every boy as a potential assailant. I do nothing. Neither does the music teacher.

Two grades later, I am walking through the science department hallway after school has let out for the day. The corridor is mostly empty, just me, a younger girl, and the two aforementioned boys. One of the latter flinch tests the girl, acting like he is going to punch her before stopping his fist just before her face. She remains silent and does not react. As they walk away, one boy says to the other, “You should have hit her. She’s black.” Afraid they might come after me, I say nothing. I do nothing. I tell no one.

It is November 2015, I am reluctantly attending my high school reunion, and I spot him, the boy – now a graying man on the early fringes of middle age – who spoke those words in the science department hallway. As soon as I see him, I think of these two incidents and wonder how many women and minorities he has harassed, bullied, intimidated, and assaulted over the last few decades in part because I did nothing to stop him.

 

Kicked

It is early spring in 1995, and my time at Needham High School is nearing an end. The best player on our tennis team is a black student who buses between his inner city home and our suburban school as part of the METCO program.

The time he loses every morning and afternoon sitting on a bus is time that I and many of my suburban-dwelling peers can use to study, do homework, seek tutoring or extra help from teachers, participate in extracurricular activities, or even just relax or sleep, all of which help directly or indirectly with our academics and college applications. We have a leg up on him based on proximity alone.

Not only is my teammate a great player, but he is also a super nice young man who goes out of his way to help us with our own games, including teaching me how to hit a kick serve. Meanwhile, I am stuck in tennis purgatory, sandwiched between a varsity roster filled with players better than me and our coach’s policy against allowing seniors on junior varsity. Coach explains to me that after three seasons together, he feels too bad to cut me, but that I should cut myself because I am not going to play. I refuse to do so and remain on the team solely as a practice hitting partner.

My personal and familial responsibilities enable me to spend every afternoon out on the courts, but my teammate has other obligations. He misses some practices, and coach tells him that if it happens again, he is gone. Then he misses another day because he has to give his brother a ride. Coach kicks him off the team, citing a lack of commitment. He cannot be in two places at once. What is he supposed to do? Yet none of his now ex-teammates come to his defense, at least, not to my knowledge.

As a result of his expulsion from the team, I get promoted to the varsity lineup and have an unexpectedly great season – thanks in part to my new kick serve – that springboards me to playing for my college.

It is my senior year at Tufts University, and not only do I get to tell potential employers that I am a collegiate athlete, thus implying that I possess a disciplined work ethic and an ability to function as part of a team, but I can add that I have been named a co-captain, suggesting that I have leadership qualities and the respect of my peers. Can my ex-teammate from high school list either of these accolades on his resume?

 

Being Followed

It is the summer of 1995, and I am a recent high school graduate working my first “real” job at Thunder Sporting Goods in Wellesley, the town in which gun-drawn police forced black Celtics player Dee Brown from his car and ordered him to lie on the ground in a case of mistaken identity five years earlier. Brown, who was originally from Florida, went on to say, “When you think of towns up North and you think of racism, you think of Boston.”

My duties primarily entail stringing tennis racquets and selling running shoes, but on this particular day, my manager gives me a different task. A neighboring retail store down the block called him to report that a black person had just been in their store and was apparently headed in our direction. My manager tells me to follow them around the store to make sure they do not steal anything.

His racist directive shocks me, yet I am intimidated by my boss, my first one ever, so I plan to keep myself busy with tasks in the same general vicinity as the shopper, but no way am I going to blatantly follow them around the store. Not a great plan, but in my 18-year-old brain, it feels like a compromise of sorts. As it turns out, the person takes their business elsewhere and never enters our store.

 

The “Bloody Shirt” Incident

It is 1996, I am a college freshman, and I agree to help a friend paint the set for her drama production. Afraid of getting paint on my nice sneakers, I wear my running shoes. It is late at night by the time I leave the scene shop, and since I have my running shoes on anyway, I decide to save some time and jog back to my dorm.

A policeman working a construction detail yells at me to stop. He sees red on my shirt and thinks I was involved in the fight he heard about over his radio. It is just paint, I tell him. Without getting close enough to me to verify my claim, he takes me at my word, and I continue running into the night. Now I have a somewhat amusing story to tell friends about the time a policeman briefly mistook me for a violent perpetrator. I am white.

 

Daewoo(d)

It is June 1999, and I am a recent college graduate. My girlfriend and I land in Las Vegas with plans to rent a car and drive to Phoenix and then San Diego for a short vacation before I enter the working world next month. The rental agency gives us the choice between two vehicles: a car to which they cannot find the key or a sketchy Daewoo without a license plate.

Somewhere in the Arizona desert, we get pulled over for speeding and driving a car without a license plate. Both policemen are friendly, and as one of them does whatever it is that cops do in their cruisers during traffic stops, the other remains by our Daewoo and jokes that maybe the last D on the car had fallen off, as he has never heard of the make before, but he knows of an electronics company by the name of Daewood.

The only emotions I am experiencing are shame and embarrassment for having been pulled over. Fear for our safety or even a theoretical notion that a routine traffic stop could turn violent never cross my mind. Despite being egregiously guilty of both offenses, we are sent on our way in our plateless car with neither a ticket nor a written warning. My girlfriend is also white.

 

Playing Fields

It is 2004, and I go back to school for nutrition at the University of Massachusetts Amherst. Driven by a fear of failure, I do everything I can to be academically perfect. In general chemistry, I answer literally every practice question in the textbook, even ones not assigned as homework. In organic chemistry, I attend the TA’s office hours, the professor’s office hours, and the on-campus tutoring department’s study groups every single week. My anxiety drives me to attend chemistry classes that I am not even enrolled in, just so I can hear the material presented over and over again.

My work ethic is as solid as osmium, but so are those of many of my classmates. Unlike some of them, I have finances working in my favor. Whereas some classmates have to load up on courses in order to finish the program as quickly as possible rather than rack up tuition costs for additional semesters, I go at a leisurely pace and never take more than four courses in a given semester. Instead of toiling endlessly at a job just to get by, my part-time gigs as a personal trainer and a dietitian’s assistant rarely sum to more than 15 hours in a given week. While our efforts are more or less equal, theirs are spread thinly over several demands whereas mine are more focused. I can afford – both literally and figuratively – to do this because I have personal savings and financial support from my parents.

Upon graduation, I have a 4.0 GPA, a handful of merit scholarships – including one for my achievements in organic chemistry – and an offer to work for free at one of the most prestigious dietetic internships in the country. Some of my classmates are not matched to an internship and are forced to pivot their career paths away from nutrition.

Because of my financial situation, I can accept my placement in the unpaid internship, the name recognition of which helps me to land my first job as a newbie registered dietitian.

 

The Iceberg’s Tip

It is June 2006, and I am in the early stages of a Seattle-to-Boston charity bicycle ride with a small group of other cyclists from around the country.

Riding into Clark Fork, a small and isolated town in the Idaho panhandle, I am shocked to see Confederate flags and pro-KKK signs openly displayed in front of a good portion of the homes.

That evening, the only black rider on our trip and I head to the local laundromat. As we walk, I tell him how surprised and horrified I am to see that such blatant racism still exists in our country, as I thought that we as a nation were past all that.

He explains to me that because I am white, I have the privilege of moving about the world largely ignorant of racism until it is glaring in my face like it is here in Clark Fork.

He is right, I realize. More than any other lesson that I learn about myself or America during our 4,024 miles across the continent, his is the one that sticks with me.

 

Community

It is the winter of 2007-2008, and my internship rotation has me working on a roving healthcare van that travels to parts of Boston that I have previously steered clear of because I associate them with violence. We park in the heart of Mattapan to conduct various screenings, such as blood sugar and blood pressure checks, distribute free condoms, and answer as best we can whatever health-related questions and concerns are voiced by our visitors, virtually all of whom are black.

On one of our lunch breaks, my preceptor takes me to Ali’s Roti Restaurant because she wants me to experience a cuisine I do not encounter in the suburbs. We browse a neighborhood grocery store so she can show me the food supply available to the neighborhood’s residents. She points out organ meats and animal parts that I never would have thought of consuming before, but they are commonplace in other cultures. Note how prevalent and cheap the sugary drinks are in comparison to other beverages, she tells me. People can only buy what they have available to them and what they can afford, she explains.

We visit a food pantry, and I talk with people eagerly lined up to receive loaves of bread so old that there is no way I would eat them myself unless I was, well, starving. While I know of the existence of food pantries and understand them in an academic sense, this is my first time really experiencing one and interacting with people who rely on them to feed themselves and their families. I go home and make myself dinner in my fully stocked kitchen.

 

Readings

It is the early summer of 2008, and I have just completed my dietetic internship. A seasoned dietitian asks me to help her at a community healthcare event. People will be coming to us for information and screenings, very similar to those that I performed while on the roving healthcare van.

“If you can’t read someone’s blood pressure,” she says, “just tell them it is 120/80.”

The ethical choice and the one that prioritizes patient care is obviously to disregard her directive, but I feel intimidated by her, and I want to stay on her good side in hopes that she might help me with my job search. Fortunately, I am pretty skilled at taking blood pressure, so I never have to cross this bridge.

For our visitors, the vast majority of whom are black, this community event is essentially their annual physical. I imagine someone coming in for a blood pressure check, giving them a fabricated 120/80 result, and sending them on their way thinking they have normal blood pressure when really they have hypertension that subsequently goes untreated and leads to a stroke.

It is June 2020. I read that blacks are 50% more likely to have a stroke in comparison to whites and I wonder: Is the biology of skin pigment really the causal factor here, or is it everything else that comes bundled with being a minority in a country fraught with social disparities and systemic racism?

 

Welcome to Food Insecurity

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The pasta aisle at the Wellesley Whole Foods on March 13, 2020.

Some of the earliest dietary guidelines emphasized high-calorie foods, like butter and margarine, because so many young men were failing their military physicals due to malnutrition. Unlike some of our ancestors, who struggled through or perished in famines or economic depressions, my generation in this country has been lucky in that we could take our access to food for granted.

Of course, numerous exceptions exist. Needham’s food pantry and the SNAP stickers on supermarket refrigerators are evidence that some of our very own neighbors struggle to get enough to eat. When I visited grocery stores on isolated Native American reservations in middle-of-nowhere regions of Montana and North Dakota in 2006, I was floored by how limited the selections were. Poverty and food deserts are not the sole factors that can limit access to food, as some of my pediatric patients growing up in restrictive households could tell us. Dieters know that food scarcity can be self-imposed.

For the rest of us, the panic surrounding COVID-19, the associated hoarding of supplies, and the resulting empty shelves have inducted us into a sensation that so much of the human race has known, but we were too privileged to experience it firsthand.

Welcome to food insecurity.

Whether or not our food supply chain is actually at risk for significant disruption, the mere perception of a threat is enough to trigger feelings of food insecurity. We see the pasta shelves and potato bins empty, the milk section vacant, frozen produce nowhere to be found, and other typical supermarket staples gone, and we feel a visceral reaction that we had better get what we can while we can. Hence, we hear stories of people making purchases that in other circumstances would make little sense. For example, one of our patients was at Costco and ended up buying a gallon of mayonnaise, a condiment she does not even typically use, just because she could get her hands on it in the midst of the frenzy.

We can understand why. Dieters know that restriction, or the mere threat of it, triggers overconsumption. Thematically, little difference exists between someone loading up a shopping cart with whatever items they can and a person who overeats on the weekend while telling themselves, “Diet starts Monday.”

When it comes time to eat, the veil of food insecurity might compel us to finish all that we have served ourselves, lest we “waste” food by leaving it uneaten. My suggestions are to understand the source of these feelings and to validate them, but also to realize you still have a choice and remove moralization from whatever decision you make.

Keep in mind that we have in our lineage ancestors who survived extraordinary circumstances and may have attempted – for better or for worse – to instill their survival skills in us. For example, my grandparents, who grew up during the Great Depression, used to pressure me to clean my plate. As another example, one of my patient’s grandmothers is a Holocaust survivor and made it through her horrific ordeal by eating whatever she could whenever she could because her next feeding opportunity was never guaranteed; like my grandparents, she pressures my patient to eat more than he can comfortably consume, too.

In terms of what to do about potential overconsumption, there is no blanket answer that is right for everyone. Instead, I encourage people to be aware of the dynamics involved in their eating decisions, including any pressures and threats related to food insecurity that might be at play.

Consider the role that stress might have in your eating decisions and know that – contrary to what diet culture tells us – emotional eating is an understandable and relatively benign response to these troubling times. We all have to deal with our stress somehow, and each of us has a different toolbox of coping strategies. Before you feel badly about eating extra in an effort to soothe yourself, remember there are people in your neighborhood reacting to their stress in much more destructive fashions, such as shooting heroin or beating up their spouse. Eventually, we can expand our repertoire of coping options so that eating is just one of many choices we can make to de-stress.

Ultimate decisions matter less than having taken the time to thoughtfully arrive at them. Weigh the pros and cons of whatever options you face while understanding that none of them is likely perfect, choose the one that in balance feels the most right to you, and know that you are neither guilty nor virtuous for whatever choice you make.

Keep in mind that these times will not last forever. Quarantines and social distancing directives will end, restaurant dining rooms will reopen, and grocery store shelves will be fully stocked once again. When they do, be on the lookout for residual behaviors that may date back to your days of food insecurity, as we know from our ancestors that such behaviors can stick around long after the threat is gone.

Immunity Boosters?

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If you are like me, you have noticed the seemingly greater-than-normal prevalence of illnesses circulating this winter, and perhaps you have suffered some of them yourself, too. No wonder people are looking for foods, nutrients, and supplements that can help them get or stay well.

So which ones help? Well, admittedly, this piece has taken a very different shape than I expected it to when I first started writing. It would be straightforward, I figured; just research the most popular immunity boosters and summarize which ones work and which ones do not. However, my expectation stemmed from having fallen into the trap of oversimplification that so often affects how our culture sees foods.

In reality, there is nuance, as I quickly remembered, and the moving parts are numerous. To suggest blanket statements about effectiveness is a variation of the oversimplified good/bad food dichotomies that are so prevalent in our culture, yet they are nonsensical without specific context.

Consider some of the variables:

Effectiveness

What does “boosting” our immune system really mean? Our immune systems are comprised of various structures and mechanisms, so when one talks of “boosting” the system, what specifically is supposedly being increased and by how much? Furthermore, do we really want to turn the dial up on our immune systems, which theoretically could result in an autoimmune disease?

When people say they want to boost their immune systems, really what they are expressing is a desire to get over an illness faster, or experience a sickness milder than what they otherwise would have, or avoid getting sick in the first place. However, these three goals are different from one another, as are the bacterial and viral invaders that exist in a wide array, so any potential immune system booster could differ in effectiveness in achieving each of the three outcomes for each of the numerous potential illnesses. Therefore, a study that demonstrates biological responses to garlic does not tell us much about bottom-line effectiveness, but rather paves the way for further study.

Dosage

The administration of a potential immune system booster has within it its own set of variables, including how much, how frequently, and which delivery method. Further complicating matters is the potential for dosage variation from person to person.

A study on vitamin C found that plasma levels of the vitamin measuring 100-200 mg/day were required for effective prevention of potential infections, but how many oranges must one consume to reach such serum levels? One, five, maybe more?

Population

Effectiveness and dosage may depend on age, weight, physical activity, hydration level, health conditions, or any of the other factors that vary from person to person. Zinc, for example, has been shown to significantly reduce the duration of cold symptoms in adults, but not children.

Risks

Looking to a food, nutrient, or supplement to help fight off an illness has potential downsides. Zinc can cause nausea when consumed orally, and it can trigger a copper deficiency if taken excessively because the two minerals compete for the same absorption sites. Meanwhile, more subjects taking echinacea dropped out of double-blind prevention trials than those taking placebos due to adverse effects. Because supplements are unregulated, we have no way of knowing if the bottle of echinacea that we purchase even contains the herb as advertised.

Somewhere out there lies a truth, but discovering it is a more difficult proposition than some realize. With so many variables at play, designing and conducting informative studies is a monumental challenge. We need large bodies of well-constructed research and replication of results from one study to the next with similar parameters, and all of that takes time, money, and effort.

The current research may yield little more than a shrug of the shoulders, but meanwhile, the population at large still yearns for an answer. “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,” says Professor Levinovitz, a religion professor who has taken to writing about nutrition in recent years because of the intersectionality between spirituality and food. “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.”

Dr. Levinovitz’s words remain true regarding ailments ranging from the coronavirus to the common cold. Nobody wants to hear that the answers are complex, nuanced, or blatantly unknown when they are anxious and looking for control over their fate.

In order to fill the void, in step those looking to gain notoriety or money. In the eyes of desperate people, the accuracy of an answer seems far less important than being able to provide one. This dynamic likely explains why so much of the misleading and biased information online regarding immunity boosting stems from commercial websites.

So which foods, nutrients, and supplements actually do help us to have shorter and milder illnesses or help us to avoid getting sick altogether? Truthfully, I have no idea. Now excuse me while I go take my elderberry syrup.

WHETHER U BELIEVE U CAN OR CAN’T ONLY SOMEWHAT MATTERS!

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Anything is possibleeeeeeeeeeeeeeeeee!” Kevin Garnett was already one of my favorite basketball players long before he came to Boston and helped the Celtics to win the 2008 championship, but his famous post-victory line made me cringe. No, Kevin, while I understand you were excited and trying to inspire, empower, and motivate, let’s be real: Anything is not possible.

The message board outside Needham’s Mitchell Elementary School triggered a similar reaction when I passed by it earlier this month. “WHETHER U BELIEVE U CAN OR CAN’T YOU’RE ABSOLUTELY RIGHT!” What are we teaching the children in this town, I questioned, and I am not even referencing the problematic grammar that seems to acquiesce to the texting generation.

As someone who was raised on The Little Engine That Could, I can appreciate the power of motivational messages that encourage children to believe in themselves, show courage, and put forth their best efforts. After all, sometimes we sell ourselves short and assume something is out of our reach, when really we could have grasped it if only we took a chance and tried.

However, the little engine’s famous mantra is “I think I can,” not “I know I can,” and the difference of just a single word reflects a broad and important truth: While we can control our behaviors to an extent, outcomes depend on more than just our actions and are often subject to factors that are out of our hands.

Competitive runners learn that time is more in their control than placement, as the latter depends on who else is racing. For example, I may go into a race fully believing in my heart that I can finish in the top ten, but if the Kenyan national team shows up to run, all the self-belief in the world is not going to overcome my competition’s skill. Even finishing time, which is more in one’s control than placement, is still subject to exterior forces, such as weather, that can slow down the entire field.

Life experience has taught me that someone using the language of certainty, such as the verb “will,” when discussing outcomes that are only somewhat in their control is a red flag that the person has lost some touch with reality. One of my first jobs as a dietitian was at a startup medical clinic that boasted that they would expand to 50 locations across the country and build a headquarters complete with a farm and even their own medical school. The leaders disapproved of and took exception to pragmatic questions about the feasibility of their stated goals and used language of certainty when discussing the company’s future. A few years after I left the company, they went out of business completely, having expanded to a total of two locations.

My gripe with the quote outside Mitchell School is not technical, unlike the guy who used logic and mathematics to pick apart the semantics of Wayne Gretzky’s famous quote; nor is it theoretical, as if I were overly worried about a potential impact that may never come to fruition.

Rather, my concerns are based on real experiences I have had with my patients, including children, who cite these sorts of motivational quotes as justification for putting themselves in harm’s way. This most commonly occurs in the context of a desire to lose weight, as some children have told me that they believe they can lose weight and keep it off if only they try hard enough.

While I admire their self-confidence, which will likely serve them well in so many other areas of life, weight regulation is the wrong place to assume that belief in oneself and hard work is enough to get the job done. The truth is that while numerous methods of inducing short-term weight loss exist, nobody has demonstrated an ability to produce long-term weight loss in more than a small fraction of the people who attempt to achieve it.

Some research has found “almost complete relapse” after three to five years, other data are more specific and suggest 90% to 95% of dieters regain all or most of the weight within five years, while other research has found that between one third and two thirds of people end up heavier than they were at baseline. Research in adolescents has found that dieters were three times more likely than non-dieters to become “overweight,” regardless of baseline weight.

To suggest that the people who regain weight simply did not believe in themselves ignores the reality that behaviors play only a small part in weight regulation while factors out of our hands, such as genetics and our gut microbial population, are largely responsible. As an example, consider folks with atypical anorexia nervosa who can implement life-threatening levels of restriction without experiencing weight loss.

Unfortunately, striving for weight loss is not a benign pursuit in which the worst-case scenario means that one simply returns to where they started. Research has shown that weight cycling – repeatedly losing and regaining weight – is associated with numerous health problems, including a higher overall death rate and an increased risk of dying from heart disease, regardless of one’s baseline weight.

Teaching self-confidence is important, but I think we can do better than overly simplistic messages that children can – and will – take literally to their own detriment.

Decision Time

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Shortly after midnight on Saturday, April 14, 2018, I had a dream in which I was at the staging area for that morning’s Newport marathon, but I had not yet checked in for the race or stored my belongings even though it was 7:13 AM, just 17 minute shy of race time. Frantic, I was trying to figure out how I was going to take care of these logistical to-do items and get to the starting line on schedule. Then I woke up.

Approximately seven hours later, I was at the staging area down in Newport for the actual marathon. The truck containing the mobile locker I had rented in advance was mysteriously not there yet. Confused and anxious, I wondered what I was going to do with all of the gear I had planned on locking up, including my wallet, keys, phone, clothes, and post-race snacks. Standing there feeling somewhat paralyzed by uncertainty, I took out my phone and checked the time. It was 7:15 AM. (Premonitions allow for a two-minute margin of error, no?)

Midnight clairvoyance and the subsequent inauspicious sunrise set the tone for the rest of my day. Eventually, I got in line for gear check, an unsecured area for runners to leave their belongings, for I could no longer wait for the mobile lockers to arrive. Good thing I did not hold out for them either, as I found out later that the driver overslept and did not arrive with the lockers until well after my race began.

As I was standing in a long line comprised mainly of runners competing in the 5K and half marathon events that were commencing later in the morning, I heard the national anthem and then saw my fellow marathoners starting down the road. After several minutes, I got the attention of a volunteer and stammered, “I don’t know what I’m doing and my race just started without me.” He told me to drop my bag, that he would take care of it, and from there I hurried to the course and crossed the starting line well after the rest of the field.

While I prepare meticulously for race-day logistics, my pre-race plans went out the window due to the chaos that ensued from the mobile lockers’ absence. About a mile down the road, I realized I had accidentally left two of my three anti-nausea medicines in the bag I checked with the volunteer. Such a mistake was quite concerning, as nausea tends to be my limiting factor in marathons, even more than muscle soreness or general fatigue.

Not having my medication only compounded problems that began with a poor training cycle due to a herniated disc in my lower back, an abdominal hernia for which surgery was scheduled six days after the marathon, and a couple of other medical hindrances. Things were not looking good already, and yet they got worse.

Quickly, my fellow runners and I discovered that hydration was going to be a problem. Unlike most marathons that offer both water and sports drinks regularly along the course, most of the beverage stations on this course featured only water. Moreover, the cups were maybe a quarter full. Subtract from that the fluid that splashed out during the drinking process, and the net amount that made it down my throat was not nearly enough to keep me hydrated. The stations that did offer a beverage other than water had a low-calorie electrolyte drink, woefully insufficient to replenish the carbohydrates expended during such an endeavor.

Despite these challenges, I was inexplicably on pace for my all-time best marathon through mile 18, but by then things were getting ridiculous. We had not had a beverage station since mile 13, no electrolyte drink since probably mile 11, and the course was in the midst of a miles-long uphill stretch that felt more challenging to me than Boston’s Heartbreak Hill ever has.

The nausea, which had been building slowly, was pronounced enough where I felt like the time was right to use the one anti-nausea medication that I remembered to bring out on the course with me. In keeping with the theme of the day, the pills promptly fell out of my Ziploc bag onto the road. The quiet tick of the medication hitting the pavement was likely inaudible to anybody else, but to me it was the thunder of my last hope for a great marathon finish crashing down.

Limited by nausea and dehydration-induced muscle cramping, my pace slowed significantly over the final miles. Around mile 25, a blister that I did not know I had burst on the bottom of my right foot, altering my gait and slowing me even further. Hobbled, I kept running and crossed the finish line limping.

Somehow, out of the day’s nonsense sprang my fastest marathon time in 15 years, but this is less a story of resolve and more a tale of someone struggling in real time to weigh the pros and cons of disregarding or honoring his body’s signals, which in this case were clearly telling me to drop out of the race.

The course was essentially a figure eight with the start, midpoint, and finish all at the center. If I was going to call it a day early, hitting the eject button at the midpoint made the most sense, so I took stock of the situation as I neared the 13.1-mile mark. Inadequate fluids, dehydration and cramping that were already setting in, insufficient medication, and memories of my 2004 Boston marathon – which ended with an ambulance ride to the emergency room – all suggested that dropping out was the sensible and safest play.

On the other hand, my speed was inexplicably fast up to that point and I did not want to take for granted that I would ever have a shot at a marathon personal best again. While I reserve the right to change my mind, I went into this race figuring it was probably my last marathon. While I enjoy the training and racing, impending parenthood had me looking at the situation from a different perspective. Long training runs take a lot out of me, so much so that I am pretty much useless the rest of the day, and I do not think it is fair to put our daughter in a position where daddy cannot play, or go to the playground, or go for a walk, or do pretty much anything at all because he ran far and needs to rest.

Even if I do decide to train for another marathon someday, who knows, I could wake up sick on race day, or sprain my ankle on a Baby Einstein guitar while heading out the door to the starting line, or suffer any item on a tremendously long list of inflictions or mishaps beyond my control that could throw the whole endeavor out the window at any point in my training cycle or at the very last instant.

As I neared the half, I was cognizant of the reality that being 13 miles into a marathon with a chance for a personal best might never happen again. For as much had gone wrong, a lot had also gone right to allow me to be in such a position. Having weighed the pros and cons, I decided to continue on with the race despite all of the reasons to stop.

Disregarding my body’s cues eventually caught up with me. A few minutes after I crossed the finish line, the nausea worsened, I was shivering (a symptom of dehydration) despite the warm temperatures, and my breathing was abnormally rapid. Laying face up in the sun while wearing a hooded sweatshirt and winter jacket did not help. With my condition deteriorating, I made my way to the medical tent.

The paramedics took my blood pressure, which was sky high compared to my norm, and I was having trouble answering their questions. While I have a history of occasionally feeling miserable after long runs, this was worse than my norm. The scariest part to me was that I was aware of my incoherence, yet I could not do anything about it. They asked me what medications I take, but I could not put together an articulate response. In my mind, I was like, “Come on, dude, you know what meds you take, just tell them,” but I was incapable of getting the words out.

The paramedics wrapped me in blankets, put me in the back of an ambulance, and cranked the heat to warm me. They gave me oxygen and placed leads to monitor my pulse, heart rhythm, and oxygen saturation. After two hours of laying on the gurney getting rehydrated and warmed, we agreed that I was well enough – but albeit still far from 100% – to leave the ambulance and make my way back to my car.

Stepping out of the ambulance, I was startled to discover that the finish area was virtually deserted, as the spectators, volunteers, race organizers, and my fellow runners had pretty much all gone home. Watching the few remaining workers disassemble the food tent and the final handful of artifacts from a post-race party that had presumably been so happy and festive just a short time earlier, I felt an eerie and unsettling sensation: loneliness.

Later that evening, Joanne commented over dinner that I looked sad. She was right. Ending up in an ambulance with a health scare is no way to conclude an event. Finishing a marathon normally yields a significant sense of accomplishment, but this time I felt conflicted and somewhat hollow. Even though completing the course was a triumph of sorts, I had mixed feelings for having put myself in unnecessary jeopardy.

Like I tell my patients who are working on listening to and honoring their internal cues: assessing hunger and fullness levels, sorting through matching criteria, checking for humming and beckoning, and utilizing other intuitive eating tools are never meant to be leading questions, and there are no such things as absolute right answers. Decisions made regarding what, when, and how much to eat matter much less than having utilized a thoughtful process to reach them.

Similarly, having considered all of the pros and cons of the options available to me at the moment I had to make a choice, I feel like continuing to run was the best course of action for me despite my body’s cues suggesting that I stop. Ultimately, I am glad I finished the race even if I did pay a price for my decision.

Just after crossing the finish line. Am I having fun or what?

Intuitive Eating: An Introduction

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This article originally appeared as a guest piece in the Progress Wellness newsletter.

What the heck is intuitive eating? We often hear the term, but what does it mean, how can it help us, what are its common misconceptions, and how can we begin to put it into practice?

First, some context: In our society, we are often taught that we cannot trust our bodies and that we need something external from ourselves to guide our eating. Hence, we have calorie counting, tracking apps, points systems, lists of foods to eat and those to avoid, meal plans, and other tools that tell us what, when, and how much to eat.

Intuitive eating, on the other hand, is a system based on the reality that contrary to popular belief, we can actually trust our bodies to guide our eating decisions. Internal signals give us information regarding our hunger and fullness, what foods will hit the spot at any given eating occasion, and how much of those foods we need to feel satisfied. Think of how much better water tastes when we are thirsty versus when we are already well hydrated, for example. Someone with anemia might not know that red meat is high in iron; they just know that a hamburger sounds mighty fine.

In contrast to external tools, intuitive eating tends to be a more peaceful and satisfying way of making decisions regarding what, when, and how much to eat. Not only that, but clinical trials have also found that intuitive eating is associated with improvements in physiological measures (blood pressure, blood lipids), health behaviors (eating and physical activity habits, dietary quality), and psychosocial outcomes (body image, self-esteem).

Whereas diet culture has rules and judgment, intuitive eating offers guidelines and flexibility, and it encourages neutral curiosity when events do not transpire as one would hope. Some people turn intuitive eating into the “hunger and fullness diet” by believing that they must eat when they reach a certain level of hunger and must stop when a certain level of fullness is attained, but such action is an oversimplification and misuse of the skills. If someone practicing intuitive eating ends up overly full, rather than beating themselves up for it and judging themselves as bad or undisciplined, they will just explore what happened to see if perhaps next time they might want to make a different decision.

Some people use intuitive eating as a weight loss tool, but doing so is a mistake. While some individuals will lose weight when they eat intuitively, many will not. By focusing on weight loss, people are likely going to end up disappointed and also stunt their development as intuitive eaters.

We are born intuitive eaters, and internal eating cues still reside in virtually all of us. Even if we fear our signals are gone, more likely they are simply buried by years of disuse, and we can uncover them and put them to use once again.

As a first step, when you are considering eating, take a moment to ask yourself, “How hungry am I right now?” You can imagine hunger and fullness existing on a linear continuum with extreme hunger at one end and extreme fullness at the opposite end. Ask yourself where on that continuum you are. Keep in mind that this is never to be a leading question, and your answer has nothing to do with permission to eat. You are simply gathering data and trying to notice the signals that your body gives you.

As a second step, if you have decided you are going to eat, rather than jumping to immediately see what your options are, take a moment to first look inward. Ask yourself if a particular flavor (sweet, salty, spicy, etc.) would hit the spot. Similarly, consider temperature (hot, frozen, chilled, room temperature, etc.), texture (crunchy, smooth, liquid, etc.), and even color. You might not have answers for all of these questions, but even knowing one of them (Temperature tends to be easiest for most people to discern.) can give you some direction. With your answer(s) in mind, now survey your choices, whether on a restaurant menu or in your own pantry or refrigerator, and try choosing the food that most matches your identified criteria.

Most people who are looking to become intuitive eaters need more help than can be found in a blog. Consider seeking the help of a registered dietitian who specializes in intuitive eating, and remember to be patient, as it can often take six months to a year, or even longer, of work and practice before your intuitive eating skills once again take their natural place as your default decision-making tools.

“Sometimes I want to binge so bad.”

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A guy two months removed from spinal fusion surgery has no business moving a 45-pound plate. For that reason, in the late spring of 2014, I introduced myself to a new personal trainer at my gym and asked him to please put away the plate that another member had left on a machine so that I could use the equipment.

Typically, I shy away from new trainers, who tend to pitch themselves to virtually every member they meet in an effort to build their client rosters. As a former trainer myself, I get it, but I also do not like being pressured. This trainer was different though, and once I saw that he was not going to push me for a sale, I began talking with him on a regular basis. That hey-can-you-please-put-this-weight-away interaction turned out to mark the beginning of what has evolved into a friendship of sorts.

In the five years since, we have chatted about superficial matters, such as the rise and fall of the Celtics, as well as issues of more substance, like marriage and fatherhood. Despite the connection we have developed and my opinion that he is generally an excellent trainer, I have never referred my patients to him because of one factor that makes it ethically impossible for me to do so: He unintentionally encourages disordered eating.

Food and eating behaviors are common topics of conversation during his training sessions. Calories, cheat days, tracking apps, Halo Top, junk food, clean eating, intermittent fasting, and willpower are just some of the buzz words and trendy features of diet culture that I frequently hear him and his clients discuss.

My patients and I sometimes talk about these topics too, but the substance of our conversations is entirely different. Whereas I work towards dismantling diet culture and helping my patients understand the harm that comes from relating to food in such a way, this trainer sees these as positives. He tracks his calories, fasts, and weighs himself regularly, and he cites his own weight loss from the past year as evidence that his behaviors are the secrets to success that his clients should replicate.

Last week, one of his clients texted him to say he was going to be a half hour late. With an unexpected chunk of free time on his hands, the trainer came over and struck up a conversation with me while I was stretching. “Do you help people lose weight?” he asked. No, I do not, and I gave him my elevator speech explanation as to why.

His response somewhat surprised me. He told me how difficult weight loss was for him, how exhausting it is to track everything he eats, and how he just cannot keep up the behaviors. “Sometimes I want to binge so bad,” he conceded. The restriction is unmaintainable, he regains the 15 pounds he lost, then resolves to become lean again, reengages in his previous diet behaviors, again loses 15 pounds, and the cycle repeats.

In the last five years, I have overheard literally hundreds of conversations he has had with his clients regarding nutrition, many of which have referenced his own eating behaviors, but never have I witnessed him disclose his struggles and concerns as he did last week when none of his clients were around to hear about them.

So, I told him about the Ancel Keys starvation study and how binge behaviors were commonplace among the subjects once the dietary restrictions placed upon them were lifted. In their excellent book, Beyond a Shadow of a Diet, Judith Matz and Ellen Frankel explain the following:

“What these men [the study’s subjects] experienced as a result of their semi-starvation is typical of feelings and behaviors exhibited by dieters. When the men entered the refeeding portion of the study, the food restrictions were lifted. Free to eat what they wanted, the men engaged in binge eating for weeks yet continued to feel ravenous. They overate frequently, sometimes to the point of becoming ill, yet they continued to feel intense hunger. The men quickly regained the lost weight as fat. Most of the subjects lost the muscle tone they enjoyed before the experiment began, and some of the men added more pounds than their pre-diet weight. Only after weight was restored did the men’s energy and emotional stability return.”

Modern day dieting, I pointed out to the trainer, is really just self-imposed starvation, and it is completely understandable that dieters respond just like the study’s subjects. It is not a matter of willpower, but rather one of biological mechanisms, honed through evolution, that resist weight loss and encourage weight gain in order to help our species survive famines and other times of food scarcity.

Soon enough, our day’s conversation came to a close. He had to get ready to train his client, and it was time for me to head home and prepare for my own day’s work. Just before we went our separate ways, he told me that his clients have no idea how hard it is for him to try to maintain his eating behaviors, and we agreed that we never really know what someone else is dealing with behind the scenes.

Our parting sentiment is also the key takeaway from this blog. Said differently, consider the words of one of our most experienced and knowledgeable colleagues, Dr. Deb Burgard, who once said, “In almost 40 years of treating eating issues, I have found that when someone sits down across from me, I have no idea what they are going to tell me they are doing with food.”

In this trainer’s case, while many of his clients see him as a role model and look to him for nutrition advice, they do not realize that he is struggling and that the behaviors they seek to emulate are actually signs of disordered eating.

Macy’s

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This month, Macy’s found themselves in hot water for selling plates, made by Pourtions, that many people criticized for encouraging eating disorders and fat shaming.

One of the plates, for example, features three concentric circles, the smallest of which is labeled “skinny jeans,” while the middle one reads “favorite jeans,” and on the largest of the three circles is emblazoned “mom jeans,” insinuating that the bigger the portion, the larger the pants size.

According to Huffington Post, Mary Cassidy, Pourtions’ president, explained, “Pourtions is intended to support healthy eating and drinking. Everyone who has appreciated Pourtions knows that it can be tough sometimes to be as mindful and moderate in our eating and drinking as we’d like, but that a gentle reminder can make a big difference. That was all we ever meant to encourage.”

Her company’s intentions do matter, for if they had purposely intended harm, then this would be a very different matter, but the impact remains the same whether their actions were malicious or an attempt at humor that missed the mark.

“These expectations can actually kill someone, and I know someone it has,” read a tweet from one responder, who elaborated that the plates spread a “toxic message, promoting even greater women beauty standards and dangerous health habits.”

Eating disorders are serious business. They can wreak havoc on one’s health, family, career, and life in general. And yes, they can be fatal. Additionally, they are more common than many people realize.

“As we all know, pressure to be thin leads to dieting, which can lead to a variety of problems, including eating disorders,” I wrote in the April 2016 issue of Boston Baseball. “These life-threatening illnesses are so common in Massachusetts that if the crowd at a sold-out Fenway Park represented a random sample of the state’s population, those in attendance with a diagnosed eating disorder would fill section 41,” which is a large section in the bleachers behind the Red Sox bullpen.

One does not even have to have a diagnosed eating disorder to be suffering the effects of diet culture and weight stigma. We see plenty of disordered eating which can be comprised of a constellation of symptoms, such as a strong good/bad food dichotomy or feelings of guilt and virtue associated with eating behaviors, that does not meet the diagnostic criteria for a specific eating disorder but can be just as disruptive and dangerous.

When we work with people recovering from eating disorders and disordered eating, we help them to uncouple judgment from their eating behaviors, and part of this work entails exploring where they learned such judgment in the first place.

The judgments implied by the Pourtions plates are so blatant that they are self-explanatory, but sometimes the message is more subtle. For example, Trader Joe’s has a line of “reduced guilt” products, such as their low-fat mac and cheese, which implies increased guilt for its full-fat counterpart. One might argue that the “reduced guilt” tag is a tongue-in-cheek marketing gimmick and is not to be taken to heart. Perhaps, but messages like these – whether in your face or toned down – are so commonplace that they are insidious.

Honoring internal eating cues is difficult to do in a society with pervasive messages that our bodies are not to be trusted. We have 100-calorie snack packs, for example, that people often utilize in an attempt to limit their consumption via an external control – in this case, the pre-portioned quantity – but the implication is that 100 calories is the correct amount to consume, that it should be enough food. In some cases, it will be, but 100 calories is an arbitrary amount of energy, and chances are low that it will just so happen to match up with someone’s hunger/fullness cues. If someone gets to the bottom of the bag and yet they are still hungry, the dissonance between their body saying, “Hey, I need more food,” and society saying, “Hey, you have already eaten enough,” is confusing and stressful.

The small print on food labels reads, “Percent Daily Values are based on a 2,000 calorie diet. Your daily values may be higher or lower depending on your calorie needs,” but time and time again, I have patients who believe they should be consuming 2,000 daily calories because food labels imply that this is the standard amount for an adult human. They then have difficulty making sense of their bodies asking for more food than that and feel tempted to restrict in an effort to match the label.

While I am not advocating for the abolition of food labels or snack packs, we have to consider the gap between impact and intent and realize that these tools might not actually be as helpful in reality as they seemed in their creators’ imaginations.

To Macy’s credit, they took the feedback they received to heart; seemingly realized that despite the humorous intent of the Pourtions products, the reality is that the plates are offensive and send harmful and dangerous messages; and consequently stopped selling them.