Decision Time

Posted on by

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“Sometimes I want to binge so bad.”

Posted on by

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.

Dietetics Within the Health at Every Size (HAES) Framework

Posted on by

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.

Crime and Punishment

Posted on by

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

Posted on by

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

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

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

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

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

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

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

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

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

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

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

Fitness Trackers

Posted on by

He Said

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

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

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

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

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

 

She Said

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

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

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

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

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

Pineapple

Posted on by

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

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

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

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

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

Sugar makes you fat?

Posted on by

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

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

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

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

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

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

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

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

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

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

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

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

Carbs

Posted on by

One of the quotes most pertinent to my work as a dietitian actually comes from a religion professor, Alan Levinovitz, who has taken to writing about nutrition in recent years because of the intersectionality of spirituality and food. He explains, “It’s terrifying to live in a place where the causes of diseases like Alzheimer’s, autism, or ADHD, or the causes of weight gain, are mysterious. So what we do is come up with certain causes for the things that we fear. If we’re trying to avoid things that we fear, why would we invent a world full of toxins that don’t really exist? Again, it’s about control. After all, if there are things that we’re scared of, then at least we know what to avoid. If there is a sacred diet, and if there are foods that are really taboo, yeah, it’s scary, but it’s also empowering, because we can readily identify culinary good and evil, and then we have a path that we can follow that’s salvific.”

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

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

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

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

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

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

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

“Good Shot”

Posted on by

“Learn to say ‘good shot,'” my physical therapist suggested as I prepared to return to competitive tennis last fall. Her advice had nothing to do with sportsmanship. Rather, it was a half-sarcastic quip that reflected her assumption that I would not be able to reach balls that I was capable of tracking down years ago and a note of caution that it might be in the best interests of my back to not even try for them if I had any doubt.

She had a point, but only to an extent. Charging forward towards a drop shot, watching the ball fall for its impending second bounce, inching the butt of the racquet handle further towards my finger tips to take advantage of whatever length I can muster, I often think to myself, “Why aren’t I there yet?” Sometimes I forget I am a 40-year-old with a bunch of titanium in my spine. Then reality hits: The ball – just out of my reach – takes its subsequent plop on the court, my physical therapist’s advice echoes in my mind, and I glance up at my opponent and offer, “Good shot.”

While my back does not directly limit my game, it has an indirect impact. Managing my back means exercising intuitively, paying attention to the feedback my body gives me, and doing my best to balance physical activity with rest. Not being able to practice and exercise as much as I once did means that my fitness level has taken a hit and my game is not quite as crisp, which consequently has affected my level of play. My second serve, for example, which used to be as consistent as the sunrise, sometimes lets me down now and I just have to accept that. The upside, however, is that my back feels so good that I never worry that I am endangering myself by trying for every ball.

Both of my tennis leagues began in October and recently concluded. My overall record between the two was an even .500, a far cry from the three-year winning streak I had from 2003 to 2006, but I have always figured that if someone more or less wins as many matches as he loses, then he is playing at the competitive level where he belongs.

My level of play was at least good enough for me to rejoin the Amherst-based team that I played for when I lived in western Massachusetts during my nutrition studies. Sports are about more than exercise and competition; they are social experiences and opportunities to hold on to an aspect of playfulness that can sometimes get lost with age. When the season wrapped up, I emailed my teammates, namechecked the guys who remained from my first stint with the club over a decade ago, and told them, “You have no idea how much I missed being part of this team.”

Returning to the team marked a milestone of sorts for me, which reminded me that we just passed the one-year anniversary of another moment of personal significance: my first time back on the court since my operations.

Tennis has always meant a lot to me, but I never quite realized just how much until I went through the prolonged period of not playing, the uncertainty of whether I ever would again, and then ultimately my return. See, the thing is, walks can be interesting, swimming is okay, lifting weights is cool sometimes, bike rides can be fun, and running is great – but tennis, that’s what I love.

January 7, 2017