Sh*t Tennis Ladies Say

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As some of you might know, I am an avid tennis player. After a very long hiatus (like 25 years long), I started playing competitive tennis in several different leagues three years ago. It has been so wonderful in so many ways – I love that I get to play a sport that is not only physically enjoyable, but is also a fabulous social network as well. My tennis teammates are some of my closest friends and I adore them.

That’s why sometimes it feels particularly upsetting when many of them speak in anti-fat, pro-diet, disordered ways about food, weight and body shape. All of these women are intelligent, well-spoken, kind-hearted people. All of these women are liberal, open-minded and generous. And nearly all of these women have either made negative comments about their own bodies, commented on others’ bodies, and have engaged in any number of diets/disordered eating patterns. It is truly mind-boggling. I have decided to write about a few of these comments partly as a way to vent, but I also feel like they can be valuable learning lessons for our readers.

Tennis friend: “Oh my goodness, did you see X on the tennis court today? She has lost/gained a ton of weight– doesn’t she look great/terrible?!”

Why these types of statements are problematic: 1) We have very limited control over our weight – our genetics are the key determinant of our body size. And while we can lose weight in the short-term, nearly 95% of dieters regain the weight, with many of them gaining even more weight than they had lost; 2) There could be a number of explanations for someone’s weight loss/gain – are they going through chemotherapy for cancer treatment? Did they recently have a traumatic life event that significantly changed their appetite? Are they on a medication that is causing them to bloat/lose their appetite? 3) These types of comments reinforce the idea that the most important thing about a woman is her physique. We are so much more than our bodies!

Ways that I choose to respond to comments like these:

“I really prefer not to talk about others’ weight – every body is different and unique.”

“Commenting on others bodies makes me uncomfortable – you really never know what someone is going through. She could have a medical condition we are unaware of.”

“Hey, how about we focus on her tennis game rather than her body shape/size?”

Tennis friend: “I’m so hungry.”

Me: “Oh, I have a granola bar in my bag – would you like it?”

Tennis friend: “Oh, no. I’m dieting.”

Why this is problematic: As Jonah and I have written about too many times to count, diets don’t work long term. When we restrict our intake and actively disregard our bodies’ hunger cues, our body goes into starvation mode. This results in a slowing of metabolism, decrease in energy, and heightened awareness and obsession with food. When you feel hungry, that is your body’s way of telling you it needs fuel. It is not a weakness. It is a necessity, like breathing air and drinking water. Not only that, once someone stops dieting (because the inherent nature of dieting is temporary), that person will likely overeat on high-fat/high-carb foods (which are your body’s preferred macronutrients in times of scarcity), and with their slowed metabolism, the weight will pile back on. Unfortunately, many women engage in this yo-yo dieting, which a number of studies have shown to be more damaging to one’s health than just maintaining a higher weight.

Ways I choose to respond to situations like this one:

“Being hungry is your body’s way of telling you it needs food. I guarantee you will feel so much better if you a eat something. I also bet you would have so much more energy to play tennis!”

“It sounds like you have been on quite a few diets over the past year. I know it’s hard to believe, but it is possible to eat in a non-restrictive way and be healthy.”

“Did you see Serena’s last tennis match? She was eating a snack on the changeover. I think she’s onto something!”

Tennis friend: “My knees/ankles/hips are killing me. If I could just lose these 20 lbs, I know that would fix the problem.”

Why this is problematic: As I wrote about several months ago, focusing on weight loss to cure physical ailments is not the right approach. Yes, biomechanically speaking, weighing less might help one’s knee pain resolve, but there is no guarantee of that. Not to mention, many people of all shapes and sizes have knee/ankle/hip pain (even thin people!). As we age, we tend to lose cartilage, and this often leads to joint pain. Sorry folks, but getting old is unavoidable! There are many ways to help joint pain that don’t involve weight loss (such as quad strengthening exercises for knee issues, medicine, wearable braces). And finally, even if someone were to lose weight to help their knee/ankle/hip pain, it is still highly unlikely they will be able to keep off that weight for any significant period of time.

Ways that I choose to respond to comments like these:

“You know, there are plenty of other strategies to use that could help your ankle pain. I would recommend talking with your doctor.”

“When I had knee pain, I started seeing a physical therapist who gave me a bunch of exercises to try to strengthen my quads – would you like his/her contact info?”

“While weight loss might initially help, it’s nearly impossible to keep off the weight, and it is likely that you will end up gaining more weight in the long run. Maybe you could find some other strategies to deal with the pain?”

At the end of the day, I really do understand why so many of these women make comments like the ones I shared above. And I also know that these comments are not just limited to the suburban female tennis playing community. We as a society have been brainwashed by the media, our doctors, our family and friends to think that it is right and normal to comment on other people’s bodies, to believe that what we choose to eat (or not eat) makes us virtuous or sinful, and to view weight loss as something that is easily achieved and maintained (all of these things being plainly false).  I just wish that we could change the conversation to one about things that really matter, like the state of the world, what we are passionate about, how our families are doing, etc.  Focusing on our bodies and what we put in them is terribly myopic. How much we could achieve if we just changed our focus.

“If you’re gay, don’t come home.”

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Joanne and I overhear so much nutrition-related garbage at our health club that I have considered creating a new blog category to chronicle it all, the working title of which is “Shit We Overhear at the Gym.” Harsh, but to the point.

Similarly candid and blunt was my experience at the gym this morning, where the topic of conversation was understandably a departure from the typical diet talk, body shaming, and nutrition myths, and instead focused on the presidential election results.

“My husband told me, ‘Anybody but her [Hillary Clinton]’, but I am really scared, and as a woman I feel so disrespected,” said the woman on the cable machine. Shortly thereafter, I ran into a friend of mine who fought back tears as she talked about what Trump’s election means for her 18-year-old daughter who now fears for her present and future.

Once I finished my workout, I headed downstairs to the men’s locker room where the guys were also discussing the election, but instead of crying they were laughing, making a joke of the whole thing. The sample size is small, granted, but the stark contrast between the male and female reactions illustrates the difference between the privileged and the vulnerable.

A friend of mine, someone I have known for close to 30 years, is the only open Trump supporter in my social circle. Once his candidate was declared the victor, he took to Facebook and gloated. After considering whether or not to respond, I decided to reach out to him in a way that I thought might help him to understand what this election result really means for our country.

When we were teenagers,” I wrote, “your father reportedly said to you, ‘If you’re gay, don’t come home.’ Fortunately, you self-identified as heterosexual, but the threat of not being accepted and welcome in your own home shook you enough that you talked with me about it. A Trump presidency makes America a less welcoming and more dangerous place for Muslims, Jews, Mexicans, women, blacks, gays, and other at-risk groups. The outrage and fear we are witnessing regarding Trump’s election is not about political parties, a change in direction, or disagreement over policies; rather, it is about millions of people with whom you and I share this country waking up today worried for their safety and freedom.

“For your sake, I am glad the crosshairs are not on you, at least not yet. Hopefully neither one of your sons is a closeted homosexual or self-identifies as a woman but is too scared to say so. For the rest of us, whether we are members of one of Trump’s targeted groups or we simply care about the people who are, his election is an ominous reminder that hate and scapegoating are alive and well in America and that history can certainly repeat itself.”

Hate is nothing new and Joanne and I have received a small taste of it. Because we advocate for size acceptance, we are occasionally bullied by online trolls who disagree with our stance that everybody, regardless of their size, is entitled to respect and equal treatment. The flack that we catch is nothing; for some of our colleagues, daily death threats are a way of life.

What is new though is the legitimacy that Trump has given to hate. Hiding behind an anonymous Twitter handle or a white sheet was one thing, but suddenly we had a presidential candidate repeatedly broadcasting his racism, misogyny, and bigotry out in the open on international television, and instead of shutting him down, we elected him. No wonder the women in the fitness center cried while the guys downstairs laughed.

As paradoxical as it may sound, intolerance of intolerance is an important stance for the safety of our community. Employees who spout hate speech at work are likely to be disciplined or fired, our legal system has hate crime laws that extend beyond whatever act is committed, and Germany banned the swastika after the fall of the Nazi regime, just to name a few examples. Regarding the latter, I reminded my friend how things worked out for that country and its people when a man rose to power on the platform that minorities were to blame for the nation’s poor economy and lack of prosperity.

We, as Americans, should be ashamed of ourselves. All of the men and women who have given their lives, either literally or figuratively, in military conflicts and civil actions over the past 240 years in pursuit of freedom and equality, and now a good portion of our citizens are eagerly trying to flush it down the toilet. We are a threat to ourselves and the world. America is an international embarrassment.

Joanne and I both want to leave. She says Toronto, I say Canada is too close for comfort and have my sights set on New Zealand. In reality though, running from the problem is no solution and we are not going anywhere. Every generation faces its struggles with hate, but the overall trend moves towards acceptance and inclusion because ordinary people hold their ground, stand up, and demand it.

Gentlemen, the Ladies Do Not Hold a Monopoly on Weight Obsession

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Gentlemen, the ladies do not hold a monopoly on weight obsession. Us guys engage in diet talk and body shaming, too. You know that, right? Maybe not, actually, as such talk is so casual and commonplace that you might not even be aware (consciously, anyway) of its pervasiveness. Consider the interaction I had yesterday evening at the gym with a male acquaintance we will call “Brad,” whom I had not seen in a long while.

Brad walked past me as I was warming up on the Arc Trainer prior to a tennis match. He had just finished a spin class and stopped to say hello. Brad and I first met 16 years ago while taking a core-strengthening class together, but the only place I had seen him in recent years was when we occasionally bumped into each other at the local pub where he eats dinner every Friday.

“You’re in nutrition. What do you order when you go there?” Brad asked with a smirk. Although he did not specifically say so, I knew exactly what he was getting at: He wanted to know if I follow a strict diet or eat freely like a perceived hypocrite, hence the mention of my profession.

Pausing, I considered the various replies at my disposal. On one hand, this was an opportunity to reeducate Brad regarding both the nature of my work and the problems with a good/bad food dichotomy. On the other hand, this was also my free time, and really I just wanted a few minutes to myself to get loose before heading out to the court, not an obligation to broach complex topics when I had neither the time nor inclination to do them justice.

“I order what I want,” I finally told him. “I order what feels like the best choice for my body at the time,” and specifically cited the pizza and nachos, which are my salty favorites to replenish the sodium I lose during long runs. (Note: By no means am I implying that one needs to exercise in order to “earn” these menu items or any other food.)

Then I asked him if he has seen our mutual friend (Let’s call him “Gary.”) who resumed exercising earlier this year after a long absence. “He’s down 40 or 50 pounds,” Brad responded, “He looks great!” Again, I paused and internally debated my next move. At the very least, I knew there was no way I would echo Brad’s praise for weight loss, as I know the damage such extolment causes, especially without fully knowing how or why someone lost weight.

“Weight loss aside, I’m just glad he is taking the time to care for himself again,” I told Brad. Like me, Gary was an avid exerciser, which is how he and I met at the gym soon after I graduated from college, but the burden of his caretaking duties increased as the health of his parents deteriorated and he no longer felt up to working out. His mother and father subsequently passed away in quick succession, which left Gary to settle their estate and figure out what to do with his own life. After everything Gary had been through, I was just happy to see him caring for himself again and returning to the activities he enjoys, including exercise, regardless of his weight.

Unfortunately, Brad did not seem to follow the gist of my sentiments and continued talking about Gary’s weight loss, adding that he has seen Gary do this at least a few times before. By “this,” Brad was referencing Gary’s history of weight cycling: alternating periods of weight loss and subsequent regain. “But not like you have to worry about that yourself,” Brad offered, looking down at my abdomen. “You’re always in great shape.”

Great shape? One of the problems with judging people for their exteriors is that we probably have no idea about the makeup of their interiors, both metaphorically and literally. Too taken aback by Brad’s comment to say anything out loud, I silently reflected upon everything I have been through over the last three years and specifically turned my thoughts to the titanium screws and rods, artifacts from my third back surgery, buried deep inside the midsection of which Brad is apparently so envious.

As is the case for everybody, my size and shape are influenced by many factors, the most significant of which are out of my hands. Among those that are at least somewhat in my control though is my history of never having tried to lose weight, which would have put me on a path most likely to end at, ironically enough, weight gain. In that sense, part of the reason I do not have a “weight problem” is because I never viewed my weight as a problem.

Think about the diet talk and various mentions of body shape and weight that Brad crammed into a casual conversation that lasted just a few minutes. Comments and discussions along these lines are so prevalent that I overhear men talking this way at the health club on a daily basis. Another recent incident comes to mind in which some of my fellow tennis players – adults, no less – bullied another player for the size of his stomach.

The problems with such talk are numerous, including: the reinforcement of the ridiculous, offensive, and dangerous notion that people of certain sizes and weights are more deserving of respect than others; the exacerbation of bullying and unequal treatment that spills well beyond health clubs and into our homes, businesses, classrooms, government initiatives, and doctor’s offices; and the pressure to pursue weight-loss endeavors that most often result in weight gain and worsened health.

Guys, this kind of talk has to stop, and the first steps toward putting it to rest are acknowledging its existence and realizing the harm we are doing to each other through our words.

One Week in October

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October 15, 2016, Ludlow, Massachusetts

Exactly 941 days after my first spinal fusion and 472 days after my second, I drove west to play a match for my old Amherst-based United States Tennis Association (USTA) team for the first time in a decade.

Over those 10 years, and particularly in the last two as I recovered from my operations, I dreamed of reuniting with them and wondered if it would ever actually happen. Intellectually, I thought it might, as my surgeon was cautiously optimistic about my chances of playing competitively again. My physical therapist was more guarded, however, particularly because the failure of my 2014 surgery reinforced that medical outcomes are rarely guaranteed no matter how certain they may seem on paper. So while in my head I thought I might compete again, in my heart I never really let myself believe it for fear of crushing disappointment.

The team roster has undergone some turnover since I last played for them in 2006, but many men still remain from my first stint and it sure was great to see them again. “You haven’t changed at all!” one of them declared. Well, on one hand, I think of the transitions I have experienced in the last decade: no longer a student, now a licensed healthcare practitioner; no longer an apartment-dwelling bachelor, now a husband, homeowner, and business owner; no longer a spry 20-something, now a balding guy in the twilight of his 30s with three back surgeries under his belt.

On the other hand, I felt at home again, just as I had before, that much was constant, and I think my teammate could see it in my face. If anything, I felt even more confident walking onto the court now than I did back in the day. Just returning to the team was in itself a victory, so whatever else I happened to achieve in the match was a bonus.

Confident and relaxed, I took advantage of an opportunity a decade in the making and destroyed my opponent 6-1, 6-0. As I quipped to my team captain, “Those 10 years of rest really helped!” Most importantly, my back felt great before, during, and after the match, which was particularly noteworthy considering what my body went through just six days earlier.

October 9, 2016, Newport, Rhode Island

My surgeon cleared me to resume running in January and I quickly ramped up my training enough to complete a 10-mile race in late February, but subsequent pain suggested that sticking to shorter distances was probably in my best interest. As the spring progressed, however, I was able to comfortably go for some longer jogs, which had me wondering if running the Newport Marathon in October might be possible. In July, my surgeon reversed his stance on long-distance running, gave me his blessing, and told me to go for it.

Go for it, I almost did not, as I nearly backed out several times on the morning of the race. As recently as two days earlier, I was excited for the event and did not feel the slightest bit nervous, but in the final hours I was sad and anxious, eerily similar to how I felt on the mornings of my surgeries. Driving south on route 24 before dawn, I thought about how easy it would be to take an exit, any exit, turn around, head north, and crawl back into bed. Just continue on to Newport, I told myself. Do not make a decision about the race yet, just drive to Newport, park, and reevaluate.

The parking lot near the starting line was still pitch black when I arrived, and torrential rain and raging winds, the extension of Hurricane Matthew that reached New England, pummeled me as soon as I stepped out of my car. Retreating to my vehicle, I considered pulling out of my space and driving home. Instead, I paused to take a deeper look at my anxieties, which mostly centered around getting sick or injured, and reminded myself of the strategies I had formulated to avoid disaster and maximize my chances of a great race.

Most importantly, I remembered other instances in my life when I felt similarly stressed and apprehensive before significant events, most notably my transcontinental bicycle ride a decade ago, only to be happy that I had followed through. In the early morning hours of June 1, 2006, my best friend drove me to a Seattle beach, my bicycle and backpack in the trunk. Sometimes he reminds me just how petrified I looked as we sat there waiting for the other riders to arrive. Indeed, part of me wanted to curl up in the fetal position in his passenger seat and ask him to drive me back to Seattle-Tacoma International Airport. Out of the 4,024 miles I traveled between Seattle and Boston, the most difficult span was the step out of his car, but I am so glad I took it.

“If you get out and run,” I told myself, as I remembered my bike trip, “in about six hours you are going to sit back down in this car seat with a medal and a tremendous sense of accomplishment.” So that’s what I did: I got out and ran. Around mile 24, I passed by my car and thought about the pep talk I had given myself early that morning. Soaking wet from the storm but excited and still full of energy, I finished the course with the fastest two miles of my entire race.

As was the case regarding my aforementioned tennis match, my back held up just fine during the marathon. “I don’t know if you fully appreciate how impressive that is after all you have been through in the past few years with your back and the surgeries,” my physical therapist wrote in an email. She may be right, as she can speak better regarding typical clinical outcomes than I can, but by no means did I take being able to complete a marathon for granted. Finishing was emotional, not just because of how close I came to backing out of the race that morning, but because for a long time I thought I would never cross another marathon finish line again.

Three days after the race, I returned to my surgeon’s office for a routine follow-up appointment. “I brought something to show you,” I told him, as I reached into my jacket pocket and retrieved my finisher’s medal. “Wow,” he laughed, “That’s amazing!” Back in March, he had gently told me my days of running marathons were probably over. He was right; they probably were.

October 8, 2016, Boston, Massachusetts

Walking from the Hynes Convention Center subway stop to its namesake for the final day of the Cardiometabolic Health Congress, I remembered limping the same route three years earlier, physically unable to continually walk the two blocks without pausing for my back pain to die down.

About a week before that day in 2013, I went to bed feeling fine, but in the morning I stood up from bed and almost fell over due to a sudden onset of severe pain radiating down my leg. Over the next few days, I hoped the symptoms would resolve as spontaneously as they arose, that I would similarly go to bed and wake up in the morning feeling back to normal. As I struggled to walk from the subway to the convention center, however, reality set in that a rapid recovery was not in the cards and I might be in serious trouble.

Thus began my three-year saga of doctors, injections, medicines, physical therapy, alternative treatments, surgical consults, operations, setbacks, and rehab that led to the present. This road has no end, as I will always have to be mindful of my back, take care of it as best I can, and live with the uncertainty that someday I may run into trouble with it again despite my efforts, but I am very happy and thankful to be where I am today.

He Said, She Said: Sports and Nutrition

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He Said

Leading up to this month’s Newport Marathon, I solicited advice from colleagues around the world as well as fellow marathoners regarding fueling strategies that might help me to avoid the nausea that plagued me in earlier endurance events.

The suggestions I received were all over the place: Eat boiled potatoes with salt late in the race. Pack maple syrup in a fanny pack and drink it periodically along the course. Eat bananas, orange wedges, gummy bears, white bread, salt bagels, or jelly beans. Drink Gatorade, Pedialyte, flat beer, coconut water, Nuun, Skratch Labs, or mix the latter two together.

As I sifted through the various suggestions, I realized I was looking at a great example of the intersection between the hard science of nutrition and intuitive eating. During endurance events, we need to replenish fluids, carbohydrates, and electrolytes, but how we do that must be individualized based on what works for each one of us; thus we need the gamut of ideas. How we determine what works best for us is by trying various approaches based upon sound nutrition guidance and personal history, paying attention to how each trial makes us feel, and basing new iterations largely on firsthand experience.

Sometimes we, as patients, have a tendency to defer entirely to our practitioners. We see comfort in directives. “Just tell me what to eat,” a patient may say. In reality, a collaborative approach tends to be much more effective in part because determining the best path involves the patient’s input and experiences. Hydrating with a particular beverage may seem great on paper, for example, but if it disagrees with the patient’s system, then we need to form a different strategy.

Patient input is one of the most significant differences between textbook nutrition and nutrition in real life, which is why Joanne and I strive to create an atmosphere of collaboration and equality at our practice. Only our patients know how various foods make them feel, so we focus on building intuitive eating skills in part so they are able to recognize and communicate these experiences.

Leading up to the marathon, I treated every athletic endeavor as an opportunity to experiment and gather data regarding how various foods and fluids made me feel. One of the drinks I tried during a tennis practice failed to hit the spot whatsoever, but better to find that out during a casual hitting session than during an important training run or the marathon itself. Another beverage worked really well once I was actually running but made me jittery beforehand. Some foods gave me cramps and made me feel sluggish whereas others settled better than I expected. All of these outcomes, even if they were not what I had hoped, represented important data.

As a result of my experiments, I knew exactly what I was going to eat and drink come race day. Breakfast consisted of white toast with peanut butter, honey, and sliced banana with orange juice and Nuun Active. Between breakfast and the start of the race, I drank Gatorade and water until a half hour before the start, at which time I downed more Nuun Active. During the race itself, I consumed Gatorade and bananas from the aid stations as well as Nuun Energy and salted pretzels that I brought with me. Worked like a charm.

If your takeaway from this column is that you should adopt my own specific food and hydration plan during your own athletic events, then unfortunately you have missed the point: the importance of individuality. As I downed the last of my Nuun Active before the start, my friend with whom I ran the race strapped small vials of maple syrup to her waist, a fueling technique that she knew from experience would work for her. If she and I had swapped strategies, both of us would probably have felt awful. We are all different, so figuring out what works best for you is a process that involves both guidance from a professional as well as your own input based on firsthand experiences.

 

She Said

From a young age, I participated in a variety of team sports, including soccer, softball, and volleyball. While I truly loved playing these sports, my family was a tennis family, in that tennis was a sport that we all learned to play as children and enjoyed playing together. As I got older, I played tennis less and less, usually just hitting the ball around for fun with my family on vacations or with Jonah on a public court during the summer. But about 3 years ago, I decided to get back into the sport that I had enjoyed so much in my youth, so I joined several local women’s tennis teams.

While my overall experience on these teams has been overwhelmingly positive, whenever the topic of food or weight comes up, I have noticed some troubling trends. Whether it is one of my teammates or one of our opponents, a number of these women exhibit quite disordered ideas about food and weight.

When I was new to one of my teams, I remember one of my teammates asking me what I do for a living. After I told her that I work primarily with individuals struggling with eating disorders (EDs), she jokingly commented, “Oh, I so wish I had an eating disorder! I just can’t seem to lose these pesky 10 pounds!” I was very quick to correct her and explain how dangerous and life-threatening EDs are and that they are not simply something that someone can choose to engage in or not to lose a few pounds.

In addition to misunderstanding EDs and the seriousness of these disorders, many of the tennis women I encounter seem to struggle with diet mentality. A couple of years ago, I remember one of my tennis friends casually mentioning that one of the primary reasons she plays so much tennis is that it allows her to eat whatever she wants. In fact, I have heard this sentiment from other tennis peers, implying that they view tennis first and foremost as a way to burn calories.

At nearly all of my tennis matches, the home team provides food for the visitors and themselves. Depending on the time of the matches, the foods offered can range from simple snacks to pretty substantial lunches. Of course, with all of this food come a lot of shame, guilt, and judgments. I overheard one group of ladies on an opposing team debating whether they would have one of the cookies offered, with one of them declaring that she does not allow herself any “white carbs.” Other times I have seen women eating only salad or protein, as they are “trying to be good.”

Diets are a hot topic at many of my matches and practices. From Paleo to Whole 30 to Shakeology, a great number of the tennis women engage in restrictive eating in one form or another. One of my tennis friends started a cleanse not too long ago because she felt like she really needed to “detox” her liver and other organs. Another friend has been eschewing carbohydrates during the week and only indulging in them on her “cheat days.” As one might imagine, I try not to engage in any diet conversations as they can become quite charged. But when I mention what I do for a living, it seems like many of these women are only too happy to talk to me about food and nutrition.

I really don’t blame these tennis ladies for their disordered ideas about food, nutrition, and weight – they are subject to the numerous fear-mongering messages we all receive from our doctors, from the media, and from our friends and family. Talking about one’s diet or weight has become so commonplace that the idea of not talking about it seems strange somehow. But just think about all of the other things we could discuss! All of the ideas and stories we could share with each other! Wouldn’t that be more fun than talking about how to lose those pesky 10 pounds?

At the end of the day, I try to pick my battles. If someone asks me about my thoughts on dieting or certain foods, I will oblige. I try to be gentle with them around my strong anti-diet philosophy as it can be quite surprising and confusing for many people. When it comes to EDs, I do my best to educate those who ask about them. So far, many of my teammates have expressed interest in the idea of intuitive eating and the non-diet approach, so I have tried to point them in the right direction by recommending books and other resources. If I can somehow help even one of them to ditch the diets and begin to appreciate their body for what it can do (e.g., play tennis!), then I will feel like I have made a difference.

Busted

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Football player Rob Ninkovich announced today that the league has suspended him for four games for taking a banned substance. Ninkovich explained, “Few things are more important to me than my name and reputation. This might call that into question for some, which has me heartbroken. I don’t want to cut any corners. I want to do things the right way, with high integrity, and that’s what I have always wanted to stand for.”

He continued, “Any supplement I’ve ever used was bought at a store. I was unaware something I bought had a substance in it that would give me a positive test because it wasn’t listed [as an ingredient]. One thing I have learned is that if a supplement is not NSF certified there are no regulations that ensure that what is on the label is 100 percent accurate. That is a hard lesson for me to learn at this stage in my career, but I take responsibility for it. It’s a mistake I made and it hurts that I won’t be there for my teammates.”

Patients frequently ask me about supplements, particularly protein powders. Pop culture nutrition is fickle. Not too long ago, we emphasized carbohydrates and feared dietary fat. Today, we are scared of carbohydrates and worship protein. As such, people who are already getting more than enough protein often feel they need even more and turn to a protein supplement.

Protein powders, like other supplements, are largely unregulated. Generally speaking, we have no idea if the contents match the listed ingredients or if the quantities reported on a bottle’s nutrition label are accurate. Back in 2008, I read a study (which I unfortunately cannot find right now) that analyzed actual protein content in various powders and found that most did not contain nearly as much protein as advertised.

Furthermore, as odd as it may initially sound, realize that manufacturers have incentive to add secret ingredients. Competition is fierce; a quick search of GNC.com yielded 512 different protein supplements. Consumers often make their selections based upon the perceived results or testimonials of others. If you are a supplement manufacturer and you want your product to stand out among the rest, to be the one that is perceived as yielding the best results, the one that gets talked about and recommended in the locker room, you may decide it is in your best interest to slip in an unlisted ingredient that produces the desired effect.

Whenever an athlete like Ninkovich gets busted and blames his supplements, the common reaction is to assume they are lying and covering for having purposely taken a performance enhancer. That may indeed be true, but we have to remember that what we often see as an excuse is also a completely plausible explanation.

You may or may not get drug tested the way that many professional athletes do, but the uncertainty of supplement contents can still impact you. Might an ingredient, listed or otherwise, interact with one of your medications, make you nauseous, give you a headache, accelerate your heart rate, or damage your liver? You could have no adverse reactions at all, wind up dead, or anywhere in between. That’s the risk.

If you use a supplement or are considering taking one, think about the potential ramifications, and remember that the lesson Ninkovich apparently learned today is actually an important lesson for us all.

An Important Shot Bricked Off the Glass

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If ESPN is going to advertise their story with a provocative before-and-after pictorial of Kevin Love’s body transformation, then let me begin my response by pointing out that the chiseled-armed latter version of Love is arguably a worse player than his earlier, pudgier self.

Sure, now that Love is LeBron’s sidekick in Cleveland rather than the focal point of offense in Minnesota, one might expect some of his numbers to be down. However, his points per game, rebounds per game, and assists per game have all worsened despite nearly identical minutes per game and playing in the midst of what should be his peak basketball years. That’s tough to do. Given that, someone will have to explain to me why we are focusing on his physique instead of his noteworthy and curious decline.

That someone, however, might not be Jackie MacMullan. Normally a fantastic sports journalist, one of the best in her field, she took a shot at an important subject with her ESPN article entitled, “From Kevin Love to Draymond Green, NBA players struggle with food more than you think,” but uncharacteristically threw up a brick.

Her piece begins with a detailed account of Love’s meticulous and rigid eating habits. “Not 10 almonds, not 18 almonds — 14 almonds,” his trainer reports. “Kevin is exactly on point. If he’s supposed to eat every two hours, then on the days when he wants to sleep in, he’ll wake up, eat and go back to sleep.” Even his teammates raise their eyebrows at his eating behaviors, which also include bringing his own food on the team plane rather than “be tempted by a postgame spread that might be high in calories and carbohydrates.”

The aforementioned content and the article’s title set up perfectly to discuss disordered eating, which is sorely in need of more attention and dialogue. “NBA players, in truth, are just like us,” the author writes, before listing various eating behaviors common to both professional athletes and laymen. A glaring omission from her list is that professionals are susceptible to dysfunctional relationships with food, eating disorders, and nutrition myths just like the rest of us. Sometimes abnormal behaviors are so prevalent that we mistake them as normal, and I think the author may have fallen into that trap.

More troubling is that instead of discussing Love’s eating habits as a red flag of concern, the author presents them in the context of his lower weight and improved endurance. Consider the impact this kind of message has on readers. For you parents out there, do not be surprised in the least when you walk into the kitchen and find your teenager counting out his or her almonds.

Furthermore, while Love is no doubt eating in a way that he believes serves him best on the court, we must remember that professional athletes often focus on the here and now while long-term risks take a back seat. The stakes are simply different for them. Professionals put their long-term health on the line for short-term rewards that are unavailable to the rest of us. Love just rushed back on the court from a concussion so he could continue playing in the NBA finals. If you suffered a similar concussion, would you risk permanent brain damage in order to play out the remainder of your YMCA rec league’s spring season? Similarly, readers must understand that following an eating plan as rigid as Love’s is risky and makes little sense for the general population.

The author turns her attention to Oliver Miller, “. . . who at his peak weighed over 375 pounds, ate so much of it [pizza] that the Suns took drastic measures, including hospitalizing him and hooking him up to IV fluids. ‘But then they found out he was ordering Domino’s from the hospital,’ [former teammate Danny] Ainge says. ‘They had to put a security guard outside the room.'” Under a photograph of Miller is a caption reading, “Oliver Miller had to be hospitalized because he couldn’t keep his eating under control. The root of his career-long battle? Pizza.”

Look, I have never met Oliver Miller or viewed his medical records, but whatever was going on with him during his playing days, I promise you that the root cause was not pizza. By talking about pizza, or any other specific food, in this way, the author further propagates the myth of food addiction. When we abandon the diet mentality, uncouple moralization from eating behaviors, break up the good/bad food dichotomy, build intuitive-eating skills, and make trigger foods available in abundance, “food addiction” typically resolves, which is the exact opposite outcome that an addiction model would predict in response to such treatment.

Even if Miller was suffering from binge eating disorder, which, as with other eating disorders, is a mental illness that gets played out through food, pizza is still not responsible for his struggles. More importantly, neither you nor I know whether or not he had such a disorder. Hopefully, one of our takeaways from our shameful treatment of Pablo Sandoval over the winter is the lesson that we cannot determine someone’s relationship with food or the presence of an eating disorder based on his or her body size or weight. The notion that we can is yet another myth.

“But it’s not as easy as simply losing weight. Becoming lighter, in many cases, often doesn’t translate into peak performance,” the author later writes. While I completely agree, the article’s subsequent content seems tenuously related at best. She discusses Roy Hibbert, who lost weight upon request by one coach and then put it back on when the Pacers hired a new coach who asked him to regain it, but that was apparently related to differing philosophies in team play between the two coaches, not a change in Hibbert’s performance. A more direct and relevant example would have been to discuss Love’s aforementioned regression despite his body transformation.

The article’s most important passage reads, “Dallas Mavericks coach Rick Carlisle says the one thing he has learned in his 27 years in the league is not to judge a player by his body type. Mavericks guard Raymond Felton, for instance, is more diligent about his diet than Russell Westbrook, yet you’d never know it by a simple eye test.” So true, but these 54 words are drowned out in a 2,910-word article largely about dieting and weight. Besides, in an age in which attention spans seem to rarely exceed 140 characters, how many readers even make it far enough in the article to reach this important paragraph?

While I commend the author for taking on this topic, her article could have been so much more than it is. She could have brought to light the societal prevalence of disordered eating, eating disorders, and nutrition misinformation so widespread that they infiltrate professional locker rooms. She could have explored how the eating habits of star athletes impact the general population, especially minors. She could have addressed the dangers and damage stemming from coupling weight with performance. Instead, she did none of those.

Ms. MacMullan, an important story is begging to be written here, and I believe you can still author it. Please consider grabbing your own rebound and putting up another shot.

Day 795/326: Tennis

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Joanne and I are grateful for everybody who has recently joined us online by liking us on Facebook, following us on Twitter, and reading our blogs. Whether you have been with us for one day or several years, we thank all of you for being part of our virtual community.

For the new folks, let me get you up to speed on a theme that occasionally pops up in my writing: the three back surgeries I have undergone, including two in the last two years, and my ongoing recovery.

Generally speaking, I am pretty guarded when it comes to talking about my own life because self-disclosure can so easily do more harm than good. However, as I headed into my 2014 operation, I decided to make an exception and document my recovery because it can be helpful for patients to remember that while our specific challenges may differ, we are coping with similar themes:

  • weighing the pros and cons of imperfect treatment options,
  • coming to grips with the reality that health outcomes are never guaranteed and only partially in our hands despite our best efforts,
  • mourning abilities or characteristics once possessed that might be gone for good,
  • accepting our new identity and discovering new ways to thrive,
  • other story lines in human existence to which patients and practitioners alike can relate.

Those of you who have followed my recovery know that my ultimate goal is to play competitive tennis again. After playing for my high school and college teams and then in adult leagues, I have been unable to compete for nearly a decade.

On Sunday, 794 days after my second surgery and 325 days after my third, I took a significant step by returning to the tennis court for the first time in three years. Unsure of what my back could handle, Joanne and I began with gentle mini tennis, just tapping the ball back and forth as we each stood at our respective service lines. No pain, to my surprise, so we backed up a little bit more into no-man’s-land. All systems still a go. Five minutes after we got to the court, we were back at our baselines hammering ground strokes to each other almost as if I never had a layoff.

Muscle memory is a crazy thing, as is modern medicine. While Joanne and I exchanged forehands and backhands, my thoughts were with everybody who contributed to my recovery: my surgeon, Dr. Jean-Valery Charles-Emile Coumans, my outpatient physical therapist, Sue Bloom, the inpatient physical therapy and nursing staff at Massachusetts General Hospital (Sorry again for pooping in my gurney, guys!), my friends, and my family, including and especially my wife.

I cannot thank them enough for helping me to find my way back home.

Court

 

An Iatrogenic Condition

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Joanne and I were watching Shark Tank the other night and I found myself wondering if the negotiations and business analyses might be so bogus that venture capitalists and MBAs get a good chuckle out of the reality show. Maybe real estate agents, general contractors, and interior designers watch Love It or List It and shake their heads. Since these programs cover topics outside my area of expertise, their content could be spot on or largely misleading and I might not know the difference.

Yesterday, the New York Times exposed the Biggest Loser for some of the long-term harm it does to its contestants and the unrealistic expectations it sets for viewers. Most notably, weight regain is pervasive despite the ex-contestants’ best efforts to keep it at bay.

For myself and other practitioners who use a similar approach to ours, some of the minutiae may have been new to us, but generally speaking, the Times piece went right into our “Yeah, no sh-t” folders, as we have known the show to be fraudulent and problematic since its inception.

Having said that, it occurs to me that for readers whose expertise lays elsewhere, this might have actually been news. If that includes you, and you were surprised to learn about the contestants’ weight regain and struggles, I hope you do not feel gullible. How were you supposed to know?

However, any seasoned obesity or metabolism researchers who found themselves surprised by these results ought to be embarrassed. Data showing commonplace weight regain among people who attempt to lose it has been available for quite a while. Even some of the most ardent weight-loss supporters reluctantly admit that although we have several methods of inducing short-term weight loss, we have no idea how to produce long-term weight loss for more than a tiny fraction of the people who attempt to achieve it.

What we see more commonly, not just in Biggest Loser contestants, but in people across the board who attempt to intentionally lose weight, is ultimate weight regain that often exceeds their baselines.

As an example, consider the following growth chart, which is from a real patient of mine (All information that could possibly reveal her identity has been removed.) Looking at her chart, hazard a guess as to when her parents and doctor first attempted to intervene with her weight. Do you think it was at age 17, when she first came to see me?

Example

No, it was just after age eight, when her BMI-for-age, which was in the 92nd percentile at the time, was deemed a problem. She was naturally a bigger kid, okay, but this fact’s implications have more to do with stigma than health. The focus on weight and a belief that an intervention would help to lower it created an iatrogenic condition. In other words, her weight became a problem because it was viewed as one.

Not only was the diagnosis off base, but the attempted interventions worsened the problem. The first diet produced a slimmer 10-year-old, who subsequently rebounded into a chunkier tween. Based on the research, this was to be the most likely result. As the patient’s teenage years began, subsequent attempts to lower her weight produced similar patterns of weight gain.

They took a child in the 92nd percentile and dieted her up to the 99th percentile, and in the process screwed up her relationships with food, her body, her doctor, and her family, all of which she is now working hard to untangle and fix.

None of that was the child’s fault, nor are the parents to blame, for they were just doing what they thought was right by following instructions from trusted practitioners.

And really, I do not blame the doctor either. Pediatricians and other primary care doctors are tasked with a tremendous responsibility to maintain basic knowledge about a myriad of conditions, everything from sore throats, to sexually transmitted diseases, to early signs of cancer, but this very demand limits them from being experts in any one field, including weight regulation.

The chain of education and direction has to begin somewhere. While these data on Biggest Loser contestants might have come as a surprise to laymen, the researchers who are responsible for the foundation of our healthcare policies should have seen them coming. That it took a New York Times article to wake them up is shameful, but they sure seem to be paying attention now, at least for the time being.

He Said, She Said: Exercise as Penance

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He Said

Data are only as useful as our understanding of them. Food labeling represents an opportunity for education while simultaneously illustrating the tremendous challenge of conveying complex ideas in a space only slightly larger than a postage stamp.

The nature of my work is one-on-one counseling, and as such, public health policy is not my area of expertise, but I can still recognize when those charged with such decisions are barking up the wrong tree. Such is the case with Britain’s idea to indicate the exercise load necessary to burn the calories in a given food.

First, remember that proclamations of calorie content are often flawed. Earlier in my career, I created nutrition labels for a university dining service as well as for cooking software. The labels that I produced reflected my best estimates based on other people’s estimates of generalities. Food manufacturers utilize a similar process to create their labels, and laws that allow rounding further cloud the picture. As the game of telephone teaches us, inaccuracies creep in with each step we take further away from the source.

Second, despite what activity trackers and cardio equipment dashboards would have us believe, estimations of caloric expenditure are similarly problematic. Your soda can may inform you that you need to run for 15 minutes to burn off the calories contained within, but this overgeneralization does not take into account your age, size, body composition, running mechanics, exercise intensity, course terrain, or any of the other variables that impact the energy that you as an individual will expend during a specific 15-minute bout of jogging.

Third, even if the data for calories consumed and burned were as accurate as can be, the implied calories-in-vs.-calories-out paradigm is an oversimplification of the complexities affecting weight regulation and overall health. Our eating and physical activity behaviors do matter, of course, but they are mere pieces in a puzzle mainly comprised of factors that are out of our hands.

Last, the presentation of a tradeoff between eating and physical activity reinforces a commonly held and problematic notion that food choices are worthy of punishment and exercise is our penance. As I recently told BuzzFeed and the Daily Meal, the good/bad food dichotomy, so prevalent in our society, links issues of morality, virtue, and guilt to our eating behaviors and is counterproductive. Nutrition and exercise activity have enough variables already without confounding them further with judgment.

A healthy relationship with food and physical activity means uncoupling moralization from such behaviors, not reinforcing the bond.

She Said

Earlier this month, Jonah and I were watching NECN when a news story came on that made us both cringe. Apparently, Britain is considering creating new food labels that not only tell the consumer how many calories are in the food, but how long the consumer would need to exercise to “burn off” that food. The proposed label would look like this: next to the calories that are listed for the food, there would be two stick figures of a person walking and running. Underneath those stick figures would be the number of minutes that someone would have to engage in either walking or running to negate the calories they consumed.

I find this idea to be highly problematic for several reasons. Firstly, as Jonah and I have written about before, the idea of “calories in, calories out,” is very much oversimplified. Most people believe that if an individual eats an extra 500 calories per day, that individual will have gained a pound of fat after a week. Unfortunately, it isn’t that simple. Numerous studies have shown that everyone processes calories differently, with some individuals getting more calories from the food they eat and others getting fewer calories from the same amount of food, resulting in some people gaining weight and others not gaining a pound.

One such study looked at identical twins and weight gain. Each pair of twins was fed an extra 1,000 calories per day for 100 days while under close observation (i.e., they were confined to a closed section of a university dorm). What the researchers found was that while the twins in each pair gained (or did not gain) the same amount of weight, there was a huge difference between the sets of twins. For instance, one pair of twins gained more than 29 pounds by the end of the intervention, while another pair only gained about 9 pounds. The conclusion that was reached was that some people are more efficient calorie burners, while others are more efficient at storing extra calories.

Aside from the fact that every body processes calories differently, I also take issue with the idea that one should be concerned with “burning off” what they are eating. In my work with people with eating disorders, there are quite a few individuals who engage in exercise bulimia. This means that these individuals will binge and then will try to compensate for the binge by over-exercising. It is a debilitating disease, and I believe that these labels would exacerbate symptoms for these individuals.

Finally, as I have written about before, I believe that exercise should not simply be viewed as a way to burn calories or to “right our wrongs.” Rather, as the Health at Every Size® principles suggest, physical activity should be a way for us to connect with our bodies by engaging in activities that we enjoy. Instead of torturing oneself in the gym to repent for last night’s cake, how about enjoying a walk outside in the sunshine to improve one’s mental, physical, and emotional health? Instead of calculating how many minutes one would need to log on the treadmill to “undo” a cookie, I think it is much healthier to use exercise as a way to feel more alive in our bodies rather than as a weight control tool.