Dietetics Within the Health at Every Size (HAES) Framework

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Following is an edited transcript of the presentation I gave at the Weight Stigma in Healthcare Settings conference at Massachusetts General Hospital (MGH) on October 18, 2018. The video of my actual presentation is available here.

I have been an MGH patient for a long time. Over the years, I have had three back surgeries here, and the staff has always been amazing. That includes my surgeon, the physical therapists, occupational therapists, nurses, and everybody who helped me during my hospitalizations. Because of the high level of care that I have received here, I feel particularly grateful to have the opportunity to talk with you today. Certainly, this 15-minute talk does not even out everything I have received over the years in terms of give and take, but it feels like a step in the right direction.

My first surgery was over 20 years ago when I was an undergrad at Tufts University, after a preseason physical for the tennis team ultimately revealed a tumor on my spine. After I recovered from the operation and graduated with a double major in mathematics and English, I worked across the river from here as an operations research analyst for the Department of Transportation.

The DOT was a fine place to work, but I realized the field of transportation was not for me. After a period of trying to figure out what I wanted to do with my career, I decided to go back to school to study nutrition at the University of Massachusetts Amherst. Once I completed my degree and my internship over at Beth Israel Deaconess Medical Center, I finally became a registered dietitian, and to be honest, I thought I was going to be amazing. The way I saw it, the basis of nutrition is biology, biology is essentially chemistry, chemistry boils down to physics, and physics is really just math. And who has a math degree? Me. Plus, with my experience in research analysis, and my background in athletics and having worked on the side as a personal trainer, I thought I had all the education and background I needed to be a great dietitian. Calories in and calories out, the Krebs cycle, grams, medical nutrition therapy, energy metabolism, what have you. If they had taught it to me, I had learned it and learned it well, so I thought I was going to be a star.

My initial patients thought I was great, too. They came to me primarily looking to lose weight or to change their body composition, and the vast majority of them did. They were thrilled with their results, some of them called me a “guru,” and they referred their friends.

Everything seemed great, but then I began to notice a pattern. In almost all cases, the initial weight loss plateaued and began to reverse. Maybe it took months, maybe it took years, but the results were almost always the same. My patients looked to me for the answers. After all, I was the one who helped them to lose the weight in the first place. But really, I had no answers. Based on my training, what I was doing should have been working, so what was the problem?

I remember how nervous my patients would be when they got on the scale or on the table for a body composition analysis, but what they did not know was that I was right there with them, as I experienced a really intense internal anxiety, praying that the numbers would be to their liking because if they were not, I was at a loss. Despite the high opinion of myself that I initially had, I began to realize the truth, which was that I kind of sucked at being a dietitian. I got into dietetics because I wanted to help people, and I realized that I was doing nothing of the sort. I felt like a fraud because, honestly, I was. I thought I had all the answers, my patients thought I had all the answers, but the truth was that I had very few of them.

Right around the time that I was experiencing this professional crisis of sorts, questioning everything that I was doing, my wife, who is also a dietitian, was attending a peer supervision group at MEDA, the Multi-Service Eating Disorders Association, so I decided to tag along. We would go around and share our most challenging cases with the group in order to learn from each other and get support that would enable us to better help our patients. When I mentioned that I was consistently seeing weight regain in my patients and I did not know what to do about it, the group leader told me that in approximately 95% of cases, people regain the weight they lose, and in about 60% of cases, people end up heavier than when they started.

My initial reaction was essentially, “Come on, there is no way that is true. If that were true, they would have taught us that in school.” So, I began asking around to other seasoned dietitians I respected, and to my surprise, they confirmed the same. Still, I was skeptical, so they pointed me towards research and articles to back up what they were saying.

For example, according to the New York Times, “After two days of testimony from leading obesity specialists, the panel said it had found no good evidence that any currently popular methods of ‘voluntary’ weight loss had much chance for long-term success. In fact, what evidence the panel could find suggested that 90 to 95 percent of dieters regain all or most of their hard-lost pounds within five years.”

Despite what they taught us in school about calories in and calories out, eat less and exercise more, and all of that, it turned out that nobody had demonstrated that they knew how to create long-term weight loss in more than a small fraction of the people who hope to achieve it. Clearly, I still had a lot to learn.

So, I began talking with more colleagues and doing the reading that they suggested, works like Beyond a Shadow of a Diet, Intuitive Eating, and Health at Every Size. My wife and I became members of ASDAH, the Association for Size Diversity and Health, and networked with colleagues all over the planet who had all come to realize that focusing on weight does not work and were instead utilizing a weight-neutral approach to care with greater success.

Knowing what my wife and I now knew, we wanted to adopt a weight-neutral approach to care, too, and maybe you are thinking to yourself that you have some interest in doing the same – maybe that is what brought you here today – but you probably realize just as we did that it is not that easy to shift gears.

Our professions demand that we further our education, hence continuing education requirements, but when new information makes us realize that we have not been helping people as we thought we were, that can be tough. One of the hardest parts for me was coming to terms with my mistakes and working through the guilt that I felt for having taken patients down a path that turned out to be less helpful than I had expected.

Beyond that, changing approaches risks losing our established patient pool, which risks our livelihoods. Our bills do not suddenly stop coming while we regroup and build up a new practice; the reality is that we all have to keep earning a living.

In a healthcare culture that is very weight focused, announcing that we are taking a weight-neutral approach not only risks losing patients, but also referral sources, our professional credibility, and maybe even our job.

For senior clinicians, including those in managerial roles, change is not easy for them either. Grants, book deals, and clinics can revolve around a given approach and professional identity built up over years and years, and changing direction can risk all of that.

My wife and I are privileged and lucky, in that circumstances and opportunity came together and we had the freedom to change, because certainly not everybody does.

Now that we have changed approaches, we find a weight-neutral approach to nutrition to be so much more helpful and beneficial than a weight-focused approach. Trying to foster long-term weight loss is generally a fruitless task, but by taking a Health at Every Size (HAES) approach, we can bypass that and go directly at whatever someone’s health concerns are.

As examples, if someone has high cholesterol, high blood pressure, or glycemic control issues, we can use medical nutrition therapy to treat these conditions directly, as opposed to attempting to use weight loss as an intermediary.

As another example, if someone is trying to improve athletic performance, we can focus directly on nutrition interventions to improve their performance, rather than hoping that weight loss will bring about increased strength, speed, endurance, or flexibility, when really it might just bring about a nutrient deficiency or an eating disorder.

A fatphobic model is particularly problematic when working with eating disorders, some of which are brought about by concerns about weight and body size in the first place. Trying to tell someone with anorexia that we will help them regain some weight – but not too much weight – reinforces weight stigma and actually colludes with the eating disorder voice, thereby hindering recovery. An approach that incorporates size acceptance, which HAES does, sets the stage for better outcomes.

Now, don’t get me wrong, being weight-neutral, as we are, is different than being anti-weight loss. If someone, through the course of behavior change, happens to lose weight as a side effect and they are happy about that, great, no problem. It’s just that the weight loss is not our goal, nor is it the focus of our work.

When we think of weight bias and the inherent issues with weight-centered care, we often think of the impact on people at the larger end of the spectrum, but the truth is that weight stigma in healthcare hurts thin people, too.

This quote is from a dietitian in Oregon. “I think there are a good number of people at the lower end of the weight spectrum who have undiagnosed sleep apnea. have a friend who was exhausted for years, did lots and lots of testing, and yet because she was thin, they never tested for sleep apnea. And sure enough, that’s what it was…five years later.”

An Australian colleague says, “I know of thin and active people, including a close friend and my physio who weren’t tested for cholesterol, diabetes, hypertension etc. because it was assumed they wouldn’t have an issue when they actually did have very high cholesterol, hypertension, or diabetes.”

According to a therapist practicing in California, “I have also had many clients tell me that because their bodies looked ‘healthy’ their providers would say, ‘Whatever you are doing, keep it up!’ even though they were throwing up, abusing laxatives, compulsively exercising, etc. To a one they talked about how utterly lonely they felt, and how it confirmed that the world did not care about what was really going on with them as long as they just kept up appearances.”

As a thin person myself, I have had doctors make incorrect assumptions about my eating habits because of my size. Whereas fat patients of mine tell me stories about how their doctors give them unsolicited nutrition advice, things like “lay off the bread basket” without even first inquiring about their bread consumption, doctors will bring up nutrition to me only to very quickly stop themselves, citing not my profession, but rather my frame, assuming that I must already be eating as they would have suggested because I am thin.

After my first back surgery, my neurologist cautioned me to “stay skinny,” telling me that if I ever thought about slacking off in terms of physical activity, to remember this conversation I was having with him. I certainly do remember that conversation, as it triggered an exercise addiction that took me over a decade to resolve. All those years, I went to him for follow-up, and he and other doctors missed blatant red flags that I had a problem because the attitude was “You’re thin, so whatever you are doing, keep it up.”

Even though I love my PCP, he is reluctant to order lab work because he sees a thin guy in front of him and tells me “I have zero concerns,” whereas I think of my family history, there are certain markers I want to be keeping tabs on, so every year we go through the same song and dance as we renegotiate what to test.

Professionally, I have had patients assume I know the secrets to getting and staying thin because I am thin myself. This is a huge issue in personal training, too, where our bodies are seen as advertisements for our services. Not only does this create a barrier, in which people who would make awesome dietitians and trainers are wary of entering the field for fear they will not be taken seriously since they do not look the part, but the presence of size-based bias in the room is a hurdle that can hinder care, conjure up false expectations, and mislead patients regarding expertise or lack thereof.

In truth, my size is mainly the product of genetics, privilege, and luck. Despite the overconfidence that I had when I finished nutrition school, the truth is that I still have a lot to learn, and I certainly have no secrets, except for maybe one, which I will share with you now: Some of my colleagues who are much bigger than me, the ones who have trouble getting patients, or referrals, or even jobs – because who wants to see the fat dietitian, obviously they do not practice what they preach, right? That’s the garbage that some people say? – Well, the truth is, the secret is, that these colleagues might be a lot bigger than me, but they are also way better clinicians than me even though I am thin.

“Just tell me what to eat”

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We have no idea what we are doing. As new and first-time parents, Joanne and I are overwhelmed with questions that outnumber our answers. Last weekend, we went out to dinner, just the two of us, and we commiserated regarding our uncertainties, unsolved dilemmas, and seemingly unpredictable behavior and sleep patterns.

“Someone can surely help us with this,” I said, referring to professional help. An expert with advanced education and certifications must exist who has all of the answers, someone who can take control, simplify the picture, and teach us the right way to parent. I paused, realizing the significance of what I was about to say next, and then continued, “I just want someone to tell me what to eat.”

One of my favorite nutrition authors, Alan Levinovitz, is actually a professor of religion, but he has taken to writing about food and eating behavior because he recognizes how themes of spirituality, including fear and a longing for control, are incorporated into how many of us relate to food.

“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,” Professor Levinovitz says. “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.”

And who can blame someone for wanting black and white food rules, a clear and crisp portion prescription, and a list of what to eat and foods to avoid? When we feel desperate and overwhelmed, we just want someone to come along who says they have the answer, the simple solution to our complex problems, and they will tell us what to do. Is that not exactly how I was feeling in the restaurant?

Similarly, who would possibly want to hear that no singular right answer exists, that what constitutes “right” is debatable, and that the situation is complex with several moving parts, some of which are not fully understood or within our power to manipulate? Who wants to be told that no set of rules or rigid structure is likely to produce long-term success, that even the most seasoned experts have gaps in their knowledge and experience? Don’t talk to me about guidelines and trial and error; my daughter is crying, and I need the answer now.

The good news, both for us and for the patients who come into my office, lean back in their chairs, cross their arms, and command, “Just tell me what to eat,” is that help and support are available, even if they are not the sharp and definitive solutions for which we pine. Joanne and I are privileged to have a pediatrician, experienced family members, and other infancy professionals who are all just a text away. While they do not have all of the answers either, we can collaborate and walk the road together.

Similarly, because of nutrition’s complexities, Joanne and I cannot just tell someone what to eat, but we are able to work with our patients to examine the factors that are influencing their eating and then formulate strategies for improvement. Other practitioners can similarly lend a hand. Therapists, for example, can be tremendously helpful for deeper issues that are getting played out through eating behaviors. Answers may be neither immediate or obvious, but together we can figure out a way to move forward.

Skeletons in the Literal Closet

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We have put out a newsletter every month since we first began writing them in May 2013, but this month’s issue almost did not happen. Between fatherhood and the chaos of our practice’s move, I had little time to write this month. Taking advantage of any windows I did have, I began to write a feature only to realize towards the end that I had already written about more or less the same subject last year. Ugh.

Just when I was about to concede that this month’s newsletter was a lost cause, I opened our office closet in the midst of packing and spotted some of my proverbial skeletons, relics from when I practiced using a very different approach than I do now, and I realized I had found this month’s newsletter topic.

Because some of our readership is comprised of former patients who worked with me when Joanne and I first established our practice (and some readers go back even further to when I was working elsewhere), they have witnessed the evolution of my work firsthand, whereas other readers probably have no idea what I am talking about and figure I always worked the way I do now. How I wish that were the case. The truth – the embarrassing truth – is that I used to be very much part of the problem.

A small cardboard box on the top shelf contained a squishy, slimy, yellow rectangle: a model of a pound of body fat. One of my colleagues gave it to me back in 2010, I think it was, with the idea that seeing the “fat” would motivate patients to lose some of their own. The connotation was clearly negative, as reinforced by the written description that came packaged with the model, and I remember feeling uneasy about using it with my patients. Even though I was practicing from a weight-centered model of care at the time, my counseling instincts suggested that scare tactics and shame were unlikely to yield any positive results. Regrettably, I did show the model to a handful of people, and the experience reinforced that my intuition was on the right track. Back in the box it went, and there it stayed until recently taking up residence in the dumpster behind our office building.

The most glaring skeletons were scattered over the closet floor: scales. Over the years, we accumulated quite the collection, including two basic home models, a medical-grade wireless body composition analyzer, and an old-fashioned physician beam scale. My schooling and internship were largely weight focused, but to be fair and completely honest, some weight-neutral lessons did creep in, such as this article that came up in my nutrition assessment course, but they were easily drowned out by the tsunami of weight-focused messages that echoed my own preconceived notions about body size and shape.

Once I began practicing, I discovered that helping people lose weight and keep it off was not nearly as easy as most of my schooling suggested it would be. My patients nervously got on the scale at their follow-up visits, but they had no idea that inside I was just as anxious, for I felt that lack of results meant that I was a bad dietitian. To be candid, I was a bad dietitian, but my problem had nothing to do with the dearth of lasting weight loss among my patient population and everything to do with my approach that focused on such numbers in the first place. Five or six years ago, I began talking with more seasoned colleagues, such as Heidi Schauster and Ellen Glovsky, who opened my eyes to the reality that weight-focused approaches to care almost never work. Shortly thereafter, I stopped weighing my patients or testing their body composition. Pitching our scales into the dumpster last week was as satisfying as it was symbolic of how my approach to care changed over our time in Wellesley.

This October, I will be speaking at Massachusetts General Hospital about weight stigma in healthcare settings, and one of the specific topics the course directors have asked me to address is my transition from a weight-focused paradigm to a weight-neutral approach to nutrition counseling. Other dietitians, as well as nurses, physical therapists, and other healthcare practitioners, will be in the audience, and it is important for them to know that we all screw up sometimes. We can come to see our mistakes, own them, learn from them, and change course. Our patient care improves, which is the bottom line.

My learning continues. As Joanne and I unpack and get settled into our Needham office, I think about the artifacts from today that I will find hidden away in our file cabinets, desk drawers, and closets upon retirement decades from now. Hopefully, I will not look back on them with embarrassment similar to what I felt upon opening the Wellesley closet, but let’s be honest, there is a lot of professional education and growth still to come.

Soolman Nutrition is moving!

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Most of you know by now that our practice is moving soon, but now we finally have the details to share with you.

Our last day practicing at our current location in Wellesley is Friday, August 24th. We will then close for a week while we move the practice three miles down the road to Needham, where we will reopen on Tuesday, September 4th.

In order to avoid confusion regarding where appointments are happening this week, we are purposely refraining from updating the address and telephone number on soolmannutrition.com until we have closed the Wellesley location. Please check back during the last week of August for these pieces of information.

The new office will have a familiar feel to it, as the office layout, size, and colors are strikingly similar to those of our Wellesley location, but you will also notice some improvements:

(1) The Needham location offers plenty of free on-street parking. No more fighting for a parking space, feeding the meter, and racing the parking enforcement officers to your car after your appointment.

(2) Situated in a quiet residential neighborhood, the Needham location offers greater privacy for those who prefer discretion while going to and from their appointments.

(3) Unlike the Wellesley office, our Needham location is fully handicap accessible, including a wheelchair lift and ADA-compliant restroom, so everybody has equal access to the care they deserve regardless of physical ability.

A less significant piece of news, but one still worth mentioning, is that we will be shortening our business name when we move the practice to Needham. Wellness is admittedly a somewhat vague term and, honestly, I do not even remember what I was getting at when I named the practice all those years ago. More than anything, its inclusion leaves people scratching their heads as to what we do. We are the Soolmans, and we help people with their nutrition, so Soolman Nutrition LLC is all we need.

Cause and Effect

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The Academy of Nutrition and Dietetics releases a daily Nutrition and Dietetics SmartBrief, which contains summaries of and links to recently released health and nutrition articles. Earlier this month, a headline in a recent issue read, “Too much sitting increases risk of early death, study says.”

The problem is that no, that is not what the study says. In fact, the HealthDay article that the SmartBrief links to states, “The study couldn’t prove cause and effect . . .” and a couple of paragraphs later, the article continues, “It’s not clear why prolonged sitting is unhealthy, Patel [lead researcher, Dr. Alpa Patel] said. It’s possible that people who spend a lot of time on the couch also have other unhealthy behaviors, such as excess snacking, she suggested.”

Okay, let’s back up a moment. First, the author who wrote the SmartBrief’s headline misrepresented the study’s findings by implying causation, and second, Dr. Patel herself seemed to disregard the limitations of her own research by labeling sitting as “unhealthy” based on an association.

This was not just a SmartBrief problem. Other news outlets picked up the story and similarly misled consumers. For example, the headline on NBC News read, “Here’s more evidence sitting too much can kill you,” with the subheading, “Sitting more than six hour [sic] a day during your free time raises the risk of early death by 19 percent.” No, that is not what the research found at all, but such sensationalism probably draws more clicks than a mundane – but more accurate – headline.

We see similarly misleading language when it comes to reporting on the research that investigates the relationship between weight and health. Headlines summarizing these pieces oftentimes imply a causal relationship between increased body weight and morbidity. Remember, however, that when researchers set out to investigate the consequences of obesity, they are also studying the impacts of weight stigma, dieting, weight cycling, socioeconomic disparity, healthcare discrepancies, and everything else that tends to come packaged with the experience of having a bigger body in today’s world.

While increased adipose tissue in and of itself could be a causal factor for certain health conditions, similar to how having fair skin increases one’s skin cancer risk, establishing a causal relationship is extremely difficult given the confounding variables. To assume causation because of correlation is premature at best, and at worst, it could be completely wrong.

Next time you see a headline that implies causation, remember that said headline might be more sensational than factual, as the actual research behind it is probably more complex and nuanced than can be accurately distilled into a single line of text or a sound bite.

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.”