Category Archives: Eating Disorders

Outer Limits

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A little over six years ago, I wrote a blog entry in which I attempted to rebut the notion that discussing topics other than food in our sessions somehow qualifies as psychology. In reference to intuitive eating, I wrote, “What does it say about how disconnected our culture teaches us to be from our internal signals regarding eating that an approach that encourages us to pay attention to said signals triggers connotations of therapy?”

After reading the blog, a friend of mine – a clinical psychologist himself – offered something along the lines of, “Maybe the reason your work is effective is because you include some psychology.” No, I bristled. Staying within my scope of practice is important to me, and certainly anything that qualifies as psychology is beyond what a dietitian can offer, I reasoned.

Given that, I have occasionally second-guessed myself when conversations with patients have strayed into more distant orbits around food. On one hand, I have tended to listen to my instinct to prioritize what my patients want to discuss and to follow the natural flow of conversation so long as what we are talking about ultimately relates to their eating. On the other hand, when conversations become less about nutrition and more about things like body image, weight stigma, or even happenings in someone’s life that are tangential to their eating, I have worried that perhaps I have inadvertently crossed the line from where a dietitian’s work ends and that of a therapist begins.

Then along came a session at the 2021 Multi-Service Eating Disorders Association (MEDA) conference that alleviated my worry and helped me to see the matter in a different light. In their talk, entitled “Staying in Your Lane – Until You Can’t: Balancing Scope of Practice and Competent Client Care,” Anna Lutz and Sandra Wartski, a dietitian and psychologist, respectively, delved into the issue of professional bounds.

One of the most validating concepts that I took away from their talk is that there is no crisp line separating the work of the two professions, but rather there is an overlap, a gradient that bleeds from one realm of expertise into the other. In other words, some topics, such as weight stigma, are appropriate for discussion with both a dietitian and therapist, and each practitioner can bring different perspectives that hopefully complement one another.

Furthermore, scope of practice is amorphous, fluid, and depends on context, such as an individual patient’s needs at a specific moment in time and the practitioner’s own comfort level. Sometimes a patient is unable to address the work at hand, and simply having a human connection is more constructive. Anna gave an example of a time when a patient was too preoccupied with other matters to discuss food, something I have experienced with patients of mine on occasion, so they spent the entirety of their appointment talking without ever discussing the patient’s eating.

Having said all that, scopes of practice can only stretch so far. If a patient raises an issue that is beyond my ability to expertly handle, such as a disclosure of trauma that they are hoping we can process together, I am responsible for making my limitations known. Similarly, a good therapist knows better than to delve into the specifics of nutrition. Part of the reason why collaboration between treatment team members is so important is because we can let each other know when something comes up that is better handled by the other practitioner.

For me, their talk validated my intuition and reassured me that the way I approach my work is well within my professional bounds. For our patients who are reading this, I hope hearing about their session resolves any lingering questions you may carry about possibly having overshared and similarly serves as encouragement to remain open going forward.

 

Exercise Checklist

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Exercise. The word alone carries a lot of meaning for many of my patients. For some of them, exercise is something that feels compulsive, that if they did not do it every day, they would feel panic. For other patients, exercise brings up old memories from childhood, such as when their parents forced them to exercise. One patient told me that when she was just eight years old, her father made her go for a run every weekday for 30 minutes to “help” her lose weight and be “healthy.” Not surprisingly, this patient has an utter hatred for running now. The word “exercise” itself can be triggering for some people as it feels intrinsically linked to diet culture. As we all know (insert sarcasm), exercise is “good for you” and therefore the more the better. “No pain, no gain” is another message that diet culture tells us about exercise. In other words, if it doesn’t hurt, you aren’t doing it right.

In my work with patients who struggle with compulsive dieting, disordered eating, and eating disorders, the question of exercise often will come up after much progress has been made with eating. A great number of my patients feel afraid to start exercising again for fear that they will get sucked back into diet culture. These patients worry that they will not be able to view exercise as something enjoyable and not required. They have concerns that their old thoughts about weight loss will start popping up again as they have associated exercise with changing their body. Some feel just completely overwhelmed at the idea of moving their body in a way that feels good because they had been so used to suffering through boring, pain-inducing workouts. And still other patients are at a loss as to what physical activity they actually enjoy.

One tool that many of my patients have found helpful is a “checklist.” It is a list of questions to consider before engaging in physical activity. The goal of this list is to help the patient check in with their body and decide whether or not they want to be physically active, and if so, what kind of activity would they like to engage in. Here is a basic checklist:

  • Am I injured or sick? If the answer is yes, then it is likely that you should be resting and not pushing yourself to be active.
  • Have I eaten enough in order to do this physical activity? Am I hungry right now? If you have not been consistently feeding yourself, exercising would be contraindicated as doing so could put a lot of stress on the body. If you are hungry, then you should eat.
  • Am I well-rested? If not, you might be too tired to be physically active right now. Perhaps your body needs a nap.
  • What am I looking to get out of this physical activity? Different forms of exercise can help our body improve endurance, strength, or flexibility. And sometimes physical activity can boost one’s mood via stress relief.
  • Do I feel like I have to do this physical activity in order to deserve food today? If you feel the answer is yes, try to reframe this thought. You deserve to eat no matter how much or how little you exercise. You do not have to “burn it to earn it.”
  • Am I using this activity as a way to try to lose weight or change how my body looks? Again, if the answer is yes, then some body image work could be indicated. Instead of asking yourself “how will this activity change my body?” try asking yourself “how will this activity make my body feel?”
  • What kind of activity would I like to engage in right now? Do I want something high intensity like spinning, something low impact like walking, or something very relaxing like yoga nidra?
  • If I don’t feel like moving my body right now, what else can I do? Maybe taking a nap or talking to a friend would feel best right now.

The checklist looks different for each patient, but at its core, it is about checking in with your body and trying to listen to what it is telling you. The more that we can practice checking in with our body around its needs – including but not limited to food, physical activity, sleep, and stress relief – we will be able to develop and foster body trust.

“Food Addiction”

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As we make our way into the fall season, it is inevitable that the topic of sweets at Halloween starts coming up with our patients. Many of our patients have a love/hate relationship with Halloween, starting when they were kids. Most remember being restricted around candy by their parents and have vivid memories of having limited access to their haul or sometimes no access at all. One recalls when her parents actually paid her $50 in exchange for her giving up all of the candy she had gathered. Another remembers sneaking her candy bag into her bedroom and eating chocolate in her closet so her mom wouldn’t see. Most of these individuals grew up feeling like they were addicted to sugar or food in general and that they could not be trusted to be around these foods.

Diet culture would have us believe that sugar/food addiction is a real phenomenon and that it is the reason for our “obesity epidemic.” Countless diet gurus and programs are dedicated to helping their clients “break the sugar habit” and cure themselves of their addiction to food. The food addiction model claims that certain foods light up the pleasure centers of the brain, which means that these foods elicit a pleasure response similar to that of drugs and alcohol. Other things that light up the pleasure centers of our brain: hugging a loved one, laughing at a funny joke, breastfeeding and/or holding your baby, listening to music you enjoy, and falling in love.

The only reason the food addiction model has been posited is because of fatphobia. Are we concerned with laughing addiction or hugging addiction? No. It’s only because people who feel that they are addicted to food are likely engaging in a lot of physical and/or mental restriction to try and control their weight. If being or becoming fat was not vilified like it is in our diet culture, people would not be restricting themselves and thereby would not feel out of control with these foods. Restriction begets bingeing.

Most studies that have been done on food addiction have been performed on mice. Interestingly, most of these studies found that the mice that were restricted from the highly palatable rewards foods and were presented these rewards at intermittent intervals were much more likely to overeat at these times. Similarly, other studies have shown that when humans are deprived of certain highly palatable foods (foods high in sugar, salt and fat), they have a heightened brain response to those foods when they see them. This means that those “forbidden” foods become much more appealing and attractive to the restrained eater than the non-restrained eater. None of the food addiction research currently controls for deprivation, meaning that they don’t measure if the subjects are currently dieting or have dieted in the past before conducting their studies.

The abstinence model of substance addiction is considered the gold standard right now. But unlike drugs and alcohol, one cannot simply abstain from food. There is a biological reason why food lights up the reward pathways in our brain – survival instinct! This causes us to seek out food when our bodies need it, which is necessary in order for our species to survive. On the other hand, we could live our lives without consuming any recreational drugs or alcohol and survive just fine.

All of this is to say that many people feel like they are addicted to food. What I would argue is that the behavior of eating might feel like an addictive or compulsive one, but that food in and of itself is not an addictive substance. So what should we do about kids and candy? My advice is to make candy (and other highly palatable foods) available on a regular basis in your home – add them to meals (i.e., have them be part of the actual meal), let them be the afternoon snack here and there. And don’t refer to these foods as “treats” or “junk” as this immediately makes them that much more appealing and also much more likely that your kids will sneak and overeat these foods when they are available. By including these foods regularly, they will lose their “shine,” and when holidays like Halloween or Christmas or Easter roll around, the magnetic pull to these foods will be markedly diminished.

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.

 

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.

Coming Out

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I am officially coming out as fat today. I’ve been thinking about doing this for a while now. This concept might seem laughable to some of you. How can someone come out as something that everyone can plainly see? Take one look at me and my size and there is no question that I am fat, but up until fairly recently, I had eschewed the title of “fat,” something that I never wanted to claim to be.

I would describe myself with euphemisms: chubby, chunky, curvy, plus size. I would try to shrink myself in public, taking up as little space as possible lest someone feel like my body imposed on them. I would keep my gaze down as I passed strangers on the street, a way of showing my own shame and embarrassment for my body. I would dress in loose, baggy clothes so no one would be forced to see my belly rolls. If I went to the beach, I would be sure to wear a cover-up the entire time unless I decided to be brave and go for a swim. Then I would sprint into the water so that bystanders would not need to be assailed by the vision of a fat woman in a bathing suit.

All of this was an attempt not to take up space in the world, to show that I, as a fat person, was aware of my horrible shortcomings and was not okay with being in this body. The world that we live in confirmed these feelings often. Microaggressions would come in the form of friends discussing another friend’s weight gain or loss, family members commenting on what I was or was not eating, and doctors suggesting changing my diet without asking me what my diet looked like in the first place.

Like any “good fatty,” from a young age I would engage in different weight loss attempts to try to shrink myself and be “healthy.” My first earnest weight loss attempt was in my senior year of high school. I had made up my mind that I would finally lose the weight that had plagued me throughout my childhood and adolescence and be thin by the time I started college in the fall. Then I could start my new adult life in a socially acceptable body and everything would be perfect. I dutifully dieted, restricting all the foods that I loved, instead living on fat-free cottage cheese, vegetables, and sadness.

My body began to shrink and everyone noticed. I got compliments, invitations to parties, acceptance. My doctor was so impressed that he told me to “keep going” and “get skinny.” Meanwhile, I had lost my period, become completely obsessed with eating as little as possible, and was a grumpy, exhausted mess. At my worst, I was exercising twice a day to try to break the plateau. I was downing sugar-free candies to prevent myself from snacking between meals. (P.S. Fun fact about those candies: They are wicked laxatives!) I would loathe going out to eat with my friends and family, as I would be faced with all the foods I no longer allowed myself to have. Food and weight were all that I could think about.

When I went off to college in the fall, the wheels fell off the proverbial wagon, and I gained back all the weight I had lost and then some. The weight loss/gain cycle continued throughout college and into my 20s as I tried diet after diet, thinking that this time it will stick. But inevitably, the weight would creep back up, and I would feel humiliated and ashamed.

Little did I know then that my experience was not unique. In an analysis of 31 long-term diet studies, researchers concluded that while individuals can expect to initially lose 5% to 10% of their weight regardless of which diet or “lifestyle change” they choose, the weight inevitably comes back, with at least one-third to two-thirds of people regaining even more weight than they had lost in the first place. Another study that looked at the effectiveness of traditional dietary and exercise interventions for weight loss determined that while there is not much long-term follow-up data in the effectiveness of these interventions, “the data that do exist suggest almost complete relapse after 3-5 years.” And those 3-5% of dieters who do manage to keep the weight off for more than 5 years spend all of their time and energy trying to stay that way, often by using disordered eating and exercise behaviors.

I remember reading an article in the New York Times about nine years ago that focused on the National Weight Control Registry (WCR), a research study that follows individuals who have lost at least 30 pounds and have kept it off for at least a year. The article featured a husband and wife who had lost over one hundred pounds each and had been on the WCR for five years. In order to maintain their weight, the couple engaged in a rigid regimen of diet and exercise. Both of them not only exercised for a minimum of two hours per day, they also weighed and measured every morsel of food they ate, logging it into a food diary. They severely limited not only their calories, but the types of calories they were eating (e.g., low carb, no desserts). The wife herself said, “It’s pretty easy to get angry with the amount of work and dedication it takes to keep this weight off,” but the alternative (i.e., gaining the weight back) was not an acceptable outcome for her.

Part of the reason I made the decision to become a registered dietitian was the hope that I could finally crack the code of weight loss. I figured, well, if I learn about all the aspects of nutrition, I will be able to lose weight, keep it off, and help others to do so, too. Before entering the nutrition program, I had dieted down to a lower weight and thus was obsessively thinking about food and my body. Interestingly, by the time I had completed my dietetic program, internship, and Master of Science in nutrition, I had again gained back all of the weight I had lost. Of course, I was quite unhappy with this development but still believed that I could figure out my weight dilemma eventually.

My first dietetic job was at an eating disorder center where I was a registered dietitian working with residential patients. It was around this time that things started to shift slightly for me. I saw how the patients were treated differently based on their body size. For instance, those patients in larger bodies, regardless if they had been admitted for restriction or not, were put on “weight maintenance” meal plans to prevent them from becoming “too fat,” while those patients in smaller bodies were encouraged to eat more to restore their weights to a “healthy weight.”

Basically, we were prescribing behaviors to one group of patients (restriction for those in larger bodies) that were considered disordered in the other group of patients. This double standard did not sit well with me, but I adhered to the guidelines at the center. At the same time, I was still fixated on shrinking my own body, terribly self-conscious of being a fat dietitian in a field known for a very specific type of person: white, female, thin. I thought to myself, “How will any of these patients take me seriously when they see my body?” I dieted once again during this period of time, and with my own wedding day approaching, I got even more obsessed about the number on the scale.

It wasn’t until after the wedding (and subsequent weight regain) that I finally had enough. This wasn’t working for me anymore, and it wasn’t for lack of trying. I had hit diet rock bottom and knew there had to be a better way. So when I learned of Health at Every Size® (HAES) and Intuitive Eating (IE) at a talk given by a colleague, I was so ready to hear the message that there was a way to live a happier and healthier life, a life where food is not the focus and where I could be free of the chains of dieting.

I delved into all of the HAES, body positive, and intuitive eating material I could find online and in various books. I attended workshops and lectures and even spent three weeks at a HAES/IE retreat. I started listening to podcasts, connecting with other HAES and IE practitioners, and before I knew it, my mindset had shifted significantly. HAES and IE spoke to me like no other paradigms or approaches, and once I learned that they are also both backed by scientific research, I was a convert.

During this time, of course I gained some weight after years of losing and gaining (in addition to having a baby), with my body finally landing in the “obese” range, at least for now. It is difficult to be in a larger body for many reasons. Doctor appointments have become more fraught as I brace myself for the weight lecture. Luckily I was able to find a weight-neutral doctor who knows not to talk to me about weight loss, but if I ever need to see a specialist, I know that inevitably my weight will come into the discussion.

Being in a larger body makes it harder to shop for clothes, fit in some spaces, and feel “normal” amongst my mostly slim friends and family. I never had to think before, “Will I fit in this seat?” But now these are things I need to consider. Being a “small-mid fat,” I want to acknowledge that I have much more privilege than those who identify as “large-fat,” “super-fat,” or “infinifat.” The hatred, mistreatment, and oftentimes abuse these individuals deal with on a daily basis make me simultaneously so angry and so sad.

Our diet-obsessed, fatphobic culture makes sure to remind me and other fat people that we are lazy, gross, sloppy gluttons who could be thin if we just tried hard enough and put down the bonbons. The overwhelming majority of people believe that weight is controllable and that if fat people just ate less and exercised more, they could be thin. Most people also believe that the health conditions that are often associated with larger body sizes (such as heart disease and diabetes) are directly caused by weight, even though there are thin people who develop these conditions, too.

While obviously what we eat and how much we move can affect our health, they are a very small part of the picture of overall health and wellness. Access to healthcare, socioeconomic status, oppression, and weight stigma have even greater impacts on our health than just diet and exercise. And just because someone does all of the “right” and “healthy” things does not guarantee that they will never become ill. Society would have us believe that the pursuit of health is a moral imperative and totally within our reach if we just try hard enough. But in the wise words of fat activist Ragen Chastain, “health is not an obligation, a barometer of worthiness, completely within our control, or guaranteed.”

Otherwise open-minded, liberal people who believe in equality and respect for those of different races, ethnicities, sexual orientations, religions, abilities, and gender identities do not consider body size diversity as something that also needs to be respected and protected. This world is not built for larger people, and existing in it can be torturous at times.

In addition to all of this, I still have a great deal of internalized fatphobia that I am constantly trying to counteract with body acceptance. I have had to come to terms that I will never likely be in a smaller body and that this is not the end of the world. At the same time, nearly everyone in my life lives and breathes the same diet culture air we live in, so it’s rare that I am not faced with some fatphobia, diet talk, or weight stigma. It’s like I’m swimming against the current of diet culture nearly 24-7, and sometimes I just want to give up and go with the flow or jump out of the water entirely. But knowing what I know about the lies of diet culture and how miserable my life was when I pursued thinness, I can’t go back.

So I am coming out as fat today to reclaim this word that has been used to taunt me and millions of other people but should honestly be just a neutral descriptor. I am a fat, fair-skinned, red-headed registered dietitian, wife, daughter, sister, friend, and mother. I am all of these things. And I am no longer going to stay in the body shame closet.

Praising Adele’s Weight Loss Is Fatphobic

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The following is a guest blog written by “Sarah,” a nurse practitioner in the Boston area, who strongly believes in utilizing Health at Every Size (HAES) and anti-diet approaches in both her personal and professional lives. She has been Joanne’s patient for about six years and is in recovery from an eating disorder.

It is no secret that our current society is obsessed with physical appearance. The perceived attractiveness of a person very much determines how they are valued, respected, and treated. This is especially true in regard to women, and to an even further extent, celebrity women. 

At this point, I am sure most of you have come across recent media stories of renowned singer Adele’s dramatic weight loss. After an Instagram post from Adele of herself in a form-fitting dress, with a caption giving a mention of her birthday and a shout-out to the first responders in the midst of the COVID-19 pandemic, comments swarmed in that had nothing to do with what she actually wrote. Now there were some comments that highlighted the fact that we should be praising Adele for her immense talent and not her appearance. Five or ten years ago, some of these comments would probably not have existed, and therefore that does highlight the progress we have made in rejecting diet culture and in the public knowledge of this movement. However, the majority of the comments praised her new, thinner, more “acceptable” body. 

Now I want to make it clear that I know absolutely nothing about Adele as a human, including her diet or exercise regimen. It is truly none of my or anyone else’s business what Adele decides to do or not to do in regard to her body. Even as someone who fully believes in HAES and is very anti-diet, if Adele did intentionally seek a smaller body, I can’t say that I blame her. Our world is a hostile place for those of us living in marginalized bodies. If you are fat, disabled, trans, poor, non-white, or any iteration of these, you are subjected to discrimination and othering. Therefore, it is no wonder why one would want to attempt to fit into a more socially respected body. 

I would normally say that it is unfair to assume anything about Adele’s means of attaining this new look, but in recent articles, she does discuss a particular diet of a VERY scary low number of calories (*trigger warning) and a rigidly structured exercise plan. Again, it is no one’s business how Adele decides to treat her body, but by the DSM standard, there is no question that she would be diagnosed with an eating disorder. I recognize that this is more of a systems issue, and those who mean well by praising her new body are operating under a fat-phobic structure. While eating disorder behaviors are considered concerning when the individual is thin, these same behaviors are encouraged for those who are in larger bodies. It is what we are taught and how we operate as a culture; it is no wonder that full recovery from eating disorders is so challenging (and oftentimes unachievable).

Now let’s get down to the real issue and meaning behind Adele’s weight loss (which really has not much to do with her at all). Body autonomy is part of the HAES movement, and I fully stand behind this for Adele or anyone else. It is the mere fact that a single picture can prompt so many comments (positive or negative) about one’s body that is the core issue here. 

The focus by others on a changing body, in a positive or negative way, often keeps people from recovering fully. If we lived in a world where a body was just a body regardless of how large or small it became, this would not even be a topic of conversation. Although it is an inevitable fact that bodies fluctuate for various reasons throughout the lifespan, we cannot seem to accept this as a society. Naomi Wolf stated: “A culture fixated on female thinness is not an obsession about female beauty, but an obsession about female obedience. Dieting is the most potent political sedative in women’s history; a quietly mad population is a tractable one.” Diet culture and fatphobia are the prime examples of this. We are taught that our worth depends on other people’s evaluation of us and that how our body looks to others matters more than how it feels to us. Especially as women, we are taught that making others happy is more important than making ourselves happy and that the most important thing is that others will like and approve of us, and therefore it is no wonder that we constantly rely on external validation to prove our worth.

Being fat and/or gaining weight is seen as the ultimate failure, and there is countless evidence of this belief expressed throughout history. We see and hear examples of this in our everyday lives, whether we recognize it or not. It is more common knowledge these days that “diets don’t work,” but we have yet to make significant progress in the idea that one’s body does not determine their worth. That is not to discredit all of the amazing progress that the HAES community has made, and as someone in a straight-size body, I cannot speak to the true experience of someone living in a larger, marginalized body. However, as a woman living in constant recovery from an eating disorder, I can say that the fear of weight gain has held me back in so many ways throughout this journey. Fatphobia truly affects everybody (whether they realize it or not) but is much more pervasive for women. 

I now know that these are reactive thoughts stemming from decades of diet culture brainwashing and the instinctual need to belong as a human. These messages have become even louder throughout the COVID-19 pandemic. Not only are we separated from many of our in-person support systems, dealing with real threats to our health and vitality, but we are relatively stuck at home with our thoughts. Although I do truly believe sitting and ruminating in these thoughts and fears can lead to growth in so many ways, it is also extremely triggering. We have less access physically and maybe financially to certain foods, and this can be triggering in itself.

To add to this, those who suffer from eating disorders and also live in larger bodies are especially vulnerable given the extreme fatphobia that knows no boundaries. There have been countless news articles claiming that people living in larger bodies are more susceptible to COVID-19. Not only is this untrue, but it is incredible healthism and just another example of diet culture profiting from our fears. Attempting to change one’s body size in the hopes of health and immortality has never worked in the past and scientifically never will. It is disappointing that these messages of blame and shame are being touted instead of compassion, inclusivity, and actual scientific facts, especially during this time. 

So how do we begin to change as a culture? By recognizing that beliefs and facts are not the same. By rejecting diet culture and recognizing that our body size or health status has nothing to do with our worth as humans and by treating others with respect and dignity just because they exist. As the wise Ragen Chastain said best: “Health is not an obligation, barometer of worthiness, or entirely within our control,” and this could not be more relevant in our current climate.

Emotional Eating in Quarantine

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Despite the major life disruption that the coronavirus quarantine has been for us personally, Jonah and I are lucky enough to be able to still work, as we are telehealth providers. While all of my patients are struggling in different ways with quarantine, one theme keeps on popping up consistently: “I feel like my emotional eating is out of control.”

Many of my patients are working on becoming intuitive eaters, and the current pandemic is making it extremely difficult for them to heal their relationship with their bodies and food. Living in these strange times is like nothing we have ever experienced before – being confined to our homes, socially distancing, and the near constant underlying fear of illness are exhausting and emotionally draining.

Some of my patients are working on the front lines of the corona crisis, taking care of patients who are severely ill. Some of my patients have lost loved ones to the virus. Others are struggling with the loneliness of isolation. In short, the past couple of months have been really, really rough. And the fact that there is no definite end point for this pandemic, that this state of limbo could continue for months on end, leaves many of us feeling hopeless and trapped.  

So when my patients tell me that they are emotionally eating, I am not at all surprised. Emotional eating in times of stress and uncertainty is normal and, honestly, to be expected. From the time that we are born, food is a source of nourishment and comfort. Food is a basic human need. From the very beginning, whether we start out nursing or bottle feeding, drinking breast milk or formula (or both), food is necessary for survival. It is designed to make us feel satiated and safe. Food is one way that our caregivers take care of us when we are babies, providing comfort when the feeling of hunger arises. This is all to say that turning to food for comfort is a completely normal thing for humans to do – it is programmed in our DNA. And feelings of comfort and safety are paramount to developing love and attachment.

The phrase “emotional eating” has been around for many years, and it always seems to be presented as a negative thing. Many of my patients characterize themselves as emotional eaters and wish that they could stop. In most cases, these patients feel as though they have “no control” around food, that they will overeat on certain comfort foods, and they inevitably feel shame after they do this. Of course, many of these patients are consumed with fears around gaining weight and feel that by engaging in emotional eating, they are likely to become larger.

To me, “emotional eating” is a phrase that was created by diet culture because at the root of it is fat phobia. Our culture is a completely fat phobic one, and one of the underlying themes is that engaging in emotional eating is a dangerous habit; if one emotionally eats regularly, they will gain weight, become fat and be unhealthy, unattractive, and unlovable. Emotional eating is seen as problematic by diet culture, and those who engage in it are deemed weak-willed and less than.

In my work, what I have found is that the amount that a patient engages in “emotional eating” is almost directly proportional to the amount of restriction (both mental and physical) in which they also engage. In other words, my patients who feel like they are emotional eaters and cannot control themselves around food are often the ones who are the most restrictive with their intake.

If you think about it, it makes sense on a biological level. Our early ancestors were often subjected to famine and food scarcity, and in order to survive during those times, their sole focus became about finding food. It is one of our most basic survival mechanisms, and it is deep within our genetic code. When we are deprived of food (whether it be deprivation imposed on us by others/circumstance or self-imposed), our primal brain is designed to focus solely on procuring food. And not just any food, mind you, but food that is calorically dense and will give us quick and lasting energy, specifically foods that are high in carbohydrates and fat. Is it any wonder that many of our “comfort foods” are often comprised mainly of carbs and fat? It is our ancient genetic code’s way of keeping us alive.

This is all to say that when we are in times of stress, anxiety and fear (like during this pandemic), it makes perfect sense that we might turn to food for comfort more often. This behavior in and of itself is not problematic; it is one of the many ways that humans cope during difficult times. Add on top of that feelings of deprivation around food (with many grocery stores running out of supplies and access to restaurants reduced), and it is no wonder that we have food on the brain more often as well. The most important thing we can do right now is not to judge ourselves for “emotionally eating” during this tough time, but to have some compassion for ourselves. We are all just trying to take care of ourselves in the best way we know how.

Stop Complimenting Weight Loss

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On the surface, complimenting someone’s weight loss seems like a benign and positive affirmation, but there are a number of reasons why doing so is problematic.

First and foremost, unless we have been told by the individual that their weight loss was intentional, we really have no clue as to why someone is losing weight. It could be due to illness, grief, or depression. It could also be as a result of an eating disorder (ED). Many of my patients say that comments about their weight loss when they were in the throes of their eating disorder fueled the disorder and made them feel like they had to keep up their disordered behaviors in order to keep their body “in check.” This goes double for patients with anorexia who are in larger bodies. These individuals often go undiagnosed with an ED because their weight loss is seen as a positive thing, never mind that they are engaging in extreme restriction and over-exercise to achieve this loss.

While I was never formally diagnosed with an ED, I myself remember when I was a teenager and engaged in very disordered eating and exercise habits and ended up losing a significant amount of weight in a short period of time. Despite the fact that I had lost my period, had very little energy, avoided going out to eat for fear of having to eat “junk” food, and overall felt awful and obsessive, I got compliment after compliment from family, friends, and even from my doctor. I even remember my doctor saying to me, “I don’t care what you are doing to lose the weight, just keep doing it!” I cringe just thinking about it!

Another reason to stop complimenting weight loss? It inherently implies that there was something wrong with the person’s body before they lost the weight. Think about it – do we ever comment on someone gaining weight in a positive light? Nope. These weight loss compliments also imply that being smaller or skinnier is better than being larger. The truth of the matter is that bodies come in all shapes and sizes, and they all deserve respect. Placing smaller bodies on a pedestal reinforces the idea that people in larger bodies are less than. This is weight stigma, and it has been shown to negatively affect us not only psychologically, but physically as well. Furthermore, since we know that 95-98% of intentional weight loss attempts result in weight regain, the silence when someone regains the weight they lost can be deafening.

Finally, and possibly the most important reason, is to stop modeling this behavior for our children. Little ones are like sponges, and from a young age, they are acutely aware of our society’s dislike of fat people. One study found that children aged 6 to 11 hold considerable negative attitudes towards their heavier peers, being more likely to describe these “overweight” peers as “mean, stupid or dirty” than average-weight peers. Other studies found that “nearly a third of children age 5 to 6 choose an ideal body size that is thinner than their current perceived size” and that “by age 6, children are aware of dieting and may have tried it”. When we compliment another’s weight loss, we are telling our kids that to be smaller is better and that being fat is a bad thing.

What can we do instead? Don’t comment on another person’s body. Full stop. If you feel compelled to give a compliment, try complimenting the person’s kindness, humor, intelligence, or other attributes not related to body shape or size.

“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.

The Kids Are Alright

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Weight Watchers, I won’t call you by your new convenient moniker “WW” designed to try to fool the public that you aren’t all about the weight. You might try to kid yourself into thinking that you are just about “wellness” and that the goal of weight loss is just a byproduct of a “healthy lifestyle change.” Nope. It’s just the same crap in a slightly different package. Any way you slice it, the only thing you care about is your bottom line, not helping your customers get healthy. If you really understood health, you would realize that a lifetime of weight cycling, weight stigma, and self-loathing are far more damaging than just staying fat. 

Weight Watchers continues to spread the lie that intentional weight loss is attainable if you just try hard enough. And if you fail at maintaining your weight loss, you, not the diet, are to blame. Bull. If your program worked, you’d be out of business. Even your former financial director Richard Samber stated as much in an interview, explaining that repeat customers are “where your business comes from.”

Where is the evidence that Weight Watchers “works” anyways? The company is famously close-lipped around their long-term success rates. In fact, they cannot demonstrate that anyone, save for a measly tiny percentage of dieters, can keep off the weight they lose for more than five years. And those who do manage to keep the weight off often use disordered eating and exercise behaviors to do so.

Intentional weight loss endeavors, whether they are through Weight Watchers or any other diet or “lifestyle change,” fail 90-95% of the time. Yet our medical community continues to push weight loss on fat patients, telling them that they are at risk of death if they don’t lose the weight. For myself and many other fat people, going to the doctor can be an anxiety-inducing experience, as we are often met with weight stigma and advice to stop eating so much (even if that’s not what’s going on). Many fat people I know just avoid going to the doctor altogether to avoid this weight shaming. Is that health-promoting behavior? I don’t think so.

The notion that weight loss is achievable and maintainable is one of those common beliefs that is put forth by diet culture. Diet culture tells us that being fat is inherently unhealthy and unappealing, that those of us who cannot lose weight are lazy, inept, unintelligent individuals who just aren’t trying hard enough. Diet culture glosses over all of the research that shows how and why our bodies fight like hell against losing weight. Diet culture ignores the facts that repeated dieting and yo-yoing is actually much more physically harmful than just maintaining a higher weight and that shaming fat individuals is not helping anyone but is taking a toll on all of our health and well-being.

Weight Watchers’ latest endeavor, launching an app that targets children aged 8-17, makes my blood boil. In the iconic words of John McEnroe, you cannot be serious, Weight Watchers. Never mind all of the eating disorders that this app will help to create and/or encourage; this app contributes to the weight stigma that plagues our society. It reinforces the idea that being fat is a bad thing and that it must be avoided at all costs. It fosters a feeling of shame in heavier kids, a feeling of being “less than.” 

As a chubby (not fat) child, I was repeatedly told by my pediatrician and my family that my body was wrong. These messages and the messages I got from diet culture led me to develop disordered beliefs around food, exercise, and my body. It wasn’t until I found Health at Every Size that I finally figured out that my body is not to blame. My body doesn’t need to change. Our weight-shaming culture needs to change. And I am honestly scared for the legions of kids and teenagers who are exposed to this toxic culture.

Weight Watchers’ app will teach kids that they cannot trust their own bodies, that their own bodies are damaged or ill-equipped to tell them what and how much they need to eat. This app will create lifelong struggles for these kids, who likely will have a disordered relationship with food and their bodies for the rest of their lives. I cannot even wrap my mind around the amount of psychological and physical damage this program will cause. 

I don’t know if it’s the fact that I have a daughter myself now that this is striking such a chord with me. I fear for her. I don’t ever want her to feel like she needs to make herself smaller to be loved, accepted, or healthy. I don’t want her to spend her life trying to change her body and fear its appetites. I want her to be confident in her body, to trust that it will tell her what it needs, and that her weight is not the measure of her worth. 

So, Weight Watchers, I hope this program fails and you disappear into the ether sooner than later.