He Said, She Said: Menu Calorie Counts

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He Said

Nutrition information has its upsides, but the data are only as useful as their interpretation. Context and framework matter; without a solid foundation, food labels and menu calorie counts can do more harm than good.

Maslow’s hierarchy of needs suggests that we, as humans, have basic needs that must be met before we can fulfill more advanced needs. Nutrition has a similar structure. At the base, someone has to have food – period. If food security is an issue, whether it is due to financial limitations, self-imposed restriction, or any other factors, then not much else matters. At the structure’s very top rests the hard science of nutrition as it relates to whatever medical conditions we may have; this is where we might talk about grams, calories, or various micronutrients. In between are issues of eating behavior that often go overlooked and yet are critical to address. Many people want to jump right to the top, but the danger in doing so is that without a solid middle, the structure is likely to fall apart.

Nutrition labels on packaged food can be helpful to someone with a healthy relationship with food and their body, but in the hands of an individual who does not have the solid middle that I previously discussed, the information can be misinterpreted, maybe reinforce a good/bad food dichotomy, and lead to or exacerbate issues like weight cycling and disordered eating.

In grocery stores, at least, we have a certain level of privacy and ambiguity that may mitigate the damage. Few shoppers probably recognize the yogurt in your cart as being higher in calories than its counterparts, and ultimately neither your fellow shoppers nor the cashier know whether that ice cream you are buying is for your kid’s birthday party or for yourself. Such uncertainties can help comfort people who fear judgment from the people around them.

Calorie counts on restaurant menus present a more complex problem. We place our orders in front of friends, family, co-workers, acquaintances, waitstaff, and fellow patrons who are primed for judgment because they – thanks to the menu – know how many calories you have elected to order for yourself.

Certainly, not everyone judges, and some of us are coated with more Teflon than others, but for many people, even the mere fear that the person across the table may be thinking “No wonder you are so fat/skinny/slow/etc.” can be enough to cause problems. The middle layer of the nutrition hierarchy involves making food decisions based on internal cues rather than external constructs. Issues of guilt, virtue, judgment, praise, and fear cloud the picture and make the establishment of this kind of relationship with food that much more difficult to attain.

Of course, restaurant nutrition information can be helpful sometimes – for example, I remember looking at the Bertucci’s website with a patient of mine in search of menu items that would mesh with his sodium restriction – but it can be provided in ways that are cognizant of potential harm. My suggestion: Post nutrition information online, as many chain restaurants already do, and have it available on site per customer request, but leave it off the menus.

 

She Said

When Jonah and I went to Bertucci’s Italian Restaurant the other night, we both realized that the menu had been redesigned (Clearly, we are regulars at Bertucci’s!). In addition to new entrees and different graphics, I was dismayed to see calorie counts prominently displayed above each and every menu item. I remember when the law was passed requiring all chain restaurants to publish their calorie information on their menus, but for some reason I had forgotten about it. (I feel like the law was passed a few years ago and just now is being implemented.) In any case, it was jarring for me to see this information, and it also made me quite concerned for my patients with eating disorders (ED).

Most, if not all, of my clients with EDs have engaged in some sort of calorie counting. Whether tallying up carbs, “macros,” or points, these patients have misused the nutrition information available to them in order to help them engage in ED behaviors. Much of my work with these individuals is around helping them to move away from the counting because it is completely antithetical to intuitive eating.

As Jonah and I have discussed before, intuitive eating is the practice of using one’s internal cues rather than depending on external factors to make food decisions. That means that someone who is an intuitive eater will (most of the time) eat when they are physically hungry and eat what they are hungry for in an amount that is satisfying. It’s about trusting your body to tell you what it needs and then honoring your body’s needs by fulfilling them.

Most of my patients with ED struggle with the idea of intuitive eating because it flies in the face of what their ED is telling them – food is to be carefully monitored and planned, certain foods are bad for you and should be off-limits, you can’t trust your hunger cues, etc. Many of these patients use calorie counting as a way to gain some control, to feel like they know exactly what they are putting in their bodies. One of my patients who is doing quite well in her ED treatment says that she still can’t shake the calorie counting habit, and she notices that this behavior ramps up when she is anxious, stressed, or overly hungry. One could say that calorie counting is a coping mechanism for many people because it helps to alleviate unpleasant feelings by giving them something concrete to focus on.

In any case, I often encourage my patients to ignore nutrition labels as it can trigger their ED. And in many cases, it is possible to (mostly) avoid this information – by purchasing unpackaged foods, buying prepared food from smaller restaurants or stores, etc. However, with this legislation, many more people will be exposed to calorie information at restaurants that they have gone to for years, and it is inescapable. I know that much of the nutrition information for chain restaurants has been available online for years and that anyone could just look up the calories on the restaurant’s website, but that at least takes a bit of effort. If someone really does not want to see this information, they will avoid it, but printing it directly on the menu makes that nearly impossible (short of never visiting the particular restaurant again).

In my opinion, I think that calorie information should be made available if the customer requests it. Everyone has the right to know what they are putting into their body. But it would be great if restaurants could also provide menus without the calorie information in order to prevent triggering individuals with ED or a history of disordered eating. It could make a number of people feel safer in these establishments, and that would make a big difference in many people’s lives.

He Said, She Said: Clean Eating

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He Said

The phrase “clean eating” never arose in nutrition school, and the only time I have seen it appear in a peer-reviewed journal article was in reference to behaviors that could be described as disordered eating. That should tell us something.

Pop culture nutrition is, after all, quite different from scientific nutrition, and “clean eating” resides squarely in the former. Given the nature of “clean eating,” let us look in that direction for its definition. “Clean eating is a deceptively simple concept,” according to Fitness Magazine. “Rather than revolving around the idea of ingesting more or less of specific things (for instance, fewer calories or more protein), the idea is more about being mindful of the food’s pathway between its origin and your plate. At its simplest, clean eating is about eating whole foods, or ‘real’ foods — those that are un- or minimally processed, refined, and handled, making them as close to their natural form as possible.”

Unsaid is the prevalent cultural implication that “minimally processed, refined, and handled” foods – “clean” foods, in other words – are healthier than foods that do not fit this description. While the concept of emphasizing foods that are less processed has some merit, the message is so oversimplified and rounded off that it is more problematic than useful.

For someone trying to keep his blood sugar steady, whole grains might be more conducive to achieving this goal than more refined grains would be because the former tend to be higher in fiber and protein compared to their white counterparts, which are stripped of these nutrients during processing (although these nutrients, and others, are sometimes added back via fortification).

In other cases though, foods that are more processed might actually be the better choice. For example, I think of one of my patients, a young woman who had lost her period for many months due to nutrient deficiency, and it was not until we increased her intake of more-refined foods – which tend to be more calorically dense – that her period returned.

What constitutes a healthy choice for someone really depends on the individual, their needs, their preferences, and other factors that are unique to them. One of the problems with the way our society talks about food is the individual gets lost. For example, we talk about foods being “good for you” or “not good for you,” but who is the “you” in question? Almost always, the phrases refer to a monolithic representation of the population that probably does not take into account the unique characteristics that separate each of us from the pack. Talking in generalities has its place (No matter who you are, drinking paint thinner is not good for you.), but way too often that kind of oversimplified talk is misleading at best and damaging at worst.

Consider the good/bad food dichotomy embedded within “clean eating.” Foods unworthy of the “clean” label are, what then, “dirty”? If you have ever dieted, remember what it was like to consume foods that were frowned upon in the context of the diet. Most likely, ingestion of a small amount of a forbidden food triggered overconsumption of said food, not because of any objective qualities inherent to the food, but rather because of the overarching subjective eating experience. We eat a little bit of “dirty” food, figure today is ruined anyway, so we might as well have some more – whether we intuitively feel like more or not – and resolve to start over “clean” tomorrow.

Clean vs. dirty, good vs. bad, sin vs. virtue, these are issues of morality and spirituality that have infiltrated the world of nutrition. Alan Levinovitz, a religion professor who has taken to writing about nutrition in recent years because of the intersectionality of spirituality and food, 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.”

Hence, we invent a construct of “clean eating” that is based less on science and more on profound issues of humanity. Understandable as this behavior may be, I cannot say strongly enough: Our relationships with food become much less fraught when we remove issues of moralization, sin, and virtue from our food choices and eating behaviors.

 

She Said

Many of my patients with eating disorders (EDs) and/or disordered eating have engaged in “clean eating” at some point in their lives. The practice of eating only unprocessed, organic, additive-free foods that have the highest nutrient value seems to be the diet du jour for many people right now. And I get it – many of us want to live the longest and healthiest lives we can, and one of the ways we can take care of ourselves is by being aware of what food we put in our bodies. Take a look at any viral “food science” article or video online and you will hear doctors, dietitians, and other health care practitioners and researchers telling you that if you eat this one food (or don’t eat this one food), you can expect to live longer (or die sooner) – as if every food decision we make over the course of the day has the power to lengthen or shorten our lives. It makes it seem like we have so much control over our health, that if only we eat the right things, we will never have illness and will live forever. Of course, this is just not true (case in point: fitness guru Bob Harper’s recent heart attack).

Given the oversimplified and misleading fashion in which food-related information is often presented in the media, nutrition must seem like an ever-changing landscape. Sure, the field is evolving just like every other facet of health care, but not as radically or quickly as the public is led to believe. Every month, a new “super food” is unveiled and promises to improve our energy, stave off cancer, prevent heart disease, and so on and so on. Never mind that just a month earlier this food might have been on the “unhealthy” food list (I’m looking at you, coconut oil.). The point is that nutrition is always evolving, and trying to keep up with all of the foods we “should” and “shouldn’t” eat is exhausting. Yet, so many of my patients are obsessed with eating only the most nutritious, healthiest foods. They emphatically believe that some foods are inherently virtuous and clean, worthy of being ingested, while other foods are a waste of money and have no business being called food. And I believe that this is a big problem.

Food is not just fuel. Let me repeat this again. Food is not just fuel. Food is connection; it’s tradition, rituals, and how we care for ourselves and others. Food can elicit some of our most cherished memories (e.g., grandma’s famous chocolate chip cookies), and food can comfort us at times. I know that “emotional eating” has been deemed a problem by many, but really, it’s okay to eat emotionally at times. In fact, it’s completely normal! For people with EDs and disordered eating, sometimes the act of eating food can be agonizing, physically, emotionally, and mentally. I can’t count how many times I have heard some version of the following from my patients: “I wish I didn’t have to eat food, that I could just get all of my needed nutrients from an IV. It would make life so much easier.” These types of sentiments break my heart.

For individuals with EDs or disordered eating, breaking foods up into “good/bad” or “clean/unhealthy” categories is de rigueur. By having clear-cut rules about what is okay and not okay to eat, these individuals feel safer and in control (Of course, we know that really, the opposite is true – these rules control the individual.). In my work with my patients, I try to help these patients challenge their food rules. This might be having them eat a formerly loved food that they have not allowed themselves to eat due to perceived lack of nutritive value. We will also discuss the value of eating a wide variety of foods, that all foods fit, even Oreos. For most of these patients, they feel that eating less-nutrient-dense foods is a waste of time, that they are “empty calories” and have no business being eaten. I have had to justify more times than I can count why Oreos might sometimes be a better choice for a snack than an apple.

What it comes down to is this: Is eating “clean” really improving your life? Aside from perhaps improving some physical health markers, how are the other aspects of your life? Are you able to share meals with others? Are you able to partake in your child’s birthday cake? Are your food rules running your life or limiting it? These questions are what I would ask a “clean eater” to consider.

He Said, She Said: Whole30®

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He Said

Earlier in my career, I worked at a medical clinic where part of my job was to put people on a 28-day “detox” program, when ordered to do so by the doctors, for reasons ranging from digestive woes to problems with fertility. For those four weeks, the patient abstained from gluten, dairy, soy, eggs, peanuts, shellfish, corn, and other foods deemed to inflame the body. At the end of the four weeks was the possibility of reintroducing the forbidden foods in systematic fashion in hopes of determining the impact of each.

If the protocol, rationale, and reasons for use sound familiar to you, that may be because they are all strikingly similar to those of the Whole30® program. “Strip them from your diet completely,” the Whole30 program’s website says of the demonized foods. “Cut out all the psychologically unhealthy, hormone-unbalancing, gut-disrupting, inflammatory food groups for a full 30 days. Let your body heal and recover from whatever effects those foods may be causing. Push the ‘reset’ button with your metabolism, systemic inflammation, and the downstream effects of the food choices you’ve been making. Learn once and for all how the foods you’ve been eating are actually affecting your day to day life, and your long term health. The most important reason to keep reading? This will change your life.”

Oh, Whole30 might change your life all right, but perhaps not in the ways that you hope. Let’s take a closer look at the program and examine three questions that address how the claims and expectations stack up against what really happens when someone embarks on such a journey.

(1) Are the excluded foods (added sugar, alcohol, grains, legumes, dairy, carrageenan, monosodium glutamate [MSG], and sulfites) really “psychologically unhealthy, hormone-unbalancing, gut-disrupting, inflammatory food groups”?

In short, no, the connection between food and our bodies is not that simple. Taking a step back in order to gain a macroscopic view of life, we see that few of us are comfortable with murkiness and uncertainty, and this overarching theme weaves its way through our relationships with food. Our yearning for crisp delineations leads to an oversimplified good/bad food dichotomy that might make us feel at ease, but really, it is nothing more than the application of scapegoating to nutrition.

Alan Levinovitz, a religion professor who has taken to writing about nutrition in recent years because of the intersectionality of spirituality and food, 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.”

(2) The Whole 30 website reads, “We want you to take this seriously, and see amazing results in unexpected areas.” What about that?

One of the confounding factors, and indeed one of the greatest challenges, with elimination diets is the power of suggestion inherent to unblinded experiments. If someone wants to test if dairy is responsible for whatever symptom is ailing him, he might first cut out dairy, wait for the symptom to subside, and then add back dairy systematically to see if the symptom returns. He knows whether he is pouring himself a glass of cow’s milk or a dairy-free alternative though, and this knowledge can influence the presence or absence of the symptom in question via placebo or nocebo effects.

For example, consider the patients I wrote about a few years ago who told me how much better they felt after cutting out gluten while they – unbeknownst to them – were still consuming gluten in abundance. They expected the exclusion of gluten to produce a positive result, so the mere belief that they had done it created the desired outcome.

By scapegoating the to-be-excluded foods before the program begins, Whole30 builds expectations that their removal will yield positive results. By guiding participants to consider “results in unexpected areas,” the program throws a bunch of crap against the wall, assuming some of it will stick. You may remember that scene in Ghost in which the psychic, played by Whoopi Goldberg, offers name after name until she hits on one that her client – who fails to see through the sham – recognizes and takes as proof of a metaphysical connection to the afterlife. Similarly, the likelihood is that over the course of 30 days, at least one facet of your wellbeing will improve, even if temporarily, and Whole30 is banking on you giving credit to the program when in fact another factor could very well be responsible. 

(3) What happens beginning on day 31 and beyond?

“We cannot possibly put enough emphasis on this simple fact—the next 30 days will change your life,” the Whole30 website reads. “It will change the way you think about food, it will change your tastes, it will change your habits and your cravings. It could, quite possibly, change the emotional relationship you have with food, and with your body. It has the potential to change the way you eat for the rest of your life.”

If your expectation is that after 30 days of abstinence, you will no longer have the taste for or cravings for the foods you excluded over the past month, you will probably be quite disappointed. “A review of the literature and research on food restriction indicates that inhibiting food intake has consequences that may not have been anticipated by those attempting such restriction,” wrote Janet Polivy, a psychology professor at the University of Toronto. “Starvation and self-imposed dieting appear to result in eating binges once food is available and in psychological manifestations such as preoccupation with food and eating, increased emotional responsiveness and dysphoria, and distractibility.”

In other words, you will likely be drawn to the excluded foods more than before the program began and overconsume them. The overeating further reinforces your preconceived notion that these foods are a problem. You may even begin to believe that you have a “food addiction” and eliminate the food again, not realizing that your presumed treatment is exacerbating the supposed problem.

Back in my days of implementing the 28-day detox program, such rebound eating was commonplace, and I had many repeat patients who did the detox over and over again in the earnest belief that the latest attempt would turn out differently than all of the ones that came before it. They blamed themselves when really the program was a setup for failure.

Taking a look at the Whole30 website, I see similar red flags planted to expunge the program of responsibility while erroneously placing the blame for potential failure squarely on the shoulders of participants. “Don’t you dare tell us this is hard. Beating cancer is hard. Birthing a baby is hard. Losing a parent is hard. Drinking your coffee black. Is. Not. Hard. You’ve done harder things than this, and you have no excuse not to complete the program as written,” the site reads. “Don’t even consider the possibility of a ‘slip.’ Unless you physically tripped and your face landed in a box of doughnuts, there is no ‘slip.’ You make a choice to eat something unhealthy. It is always a choice, so do not phrase it as if you had an accident.”

See through the enticing marketing and realize that diets like Whole30 are unlikely to produce long-term positive results and are more likely to pave the way for weight cycling and an unhealthy relationship with food while making you feel responsible for their failures.

 

She Said

While the Whole30 program has been around for a few years (It was created in 2009 by two “sports nutritionists.”), it feels like I have been hearing a lot more about it recently. And since we recently rang in the New Year, there seemed to be a surge of Whole30 talk both inside and outside my office. Many of my patients have asked me about the eating plan that emphasizes eating “whole” (i.e., minimally processed) foods while avoiding dairy, soy, sugar, alcohol, grains and legumes for 30 days and then strategically reintroducing these foods one by one to see how they affect one’s health, energy and stress levels. One patient of mine is getting married this month, and her husband-to-be and many of her family members are following the Whole30 to start “shedding for the wedding.” Go on any “healthy eating” Instagram page and you will find #Whole30 all over the place, with people posting their “clean” meals and extolling the virtues of this way of eating.

As you can guess, I am not a fan of Whole30, or any fad diet for that matter. Not only is it just another way for someone to try to manipulate their food using external rules to shrink their waistline, but it also promotes the “good food/bad food” dichotomy, which can lead to a lifetime of dieting and never having a healthy relationship with food or one’s body. For someone who is predisposed to developing an eating disorder (ED), following a plan like Whole30 could be especially dangerous because diets are often the gateway to EDs. In fact, many of my patients who struggle with EDs have tried Whole30 (or similar eating plans) and have found that it worsened their ED symptoms.

The tricky thing about the Whole30 is that on the surface it sounds good – the authors talk about the health benefits one can expect to reap by following the program and how eating unprocessed foods can improve one’s health and happiness. The plan suggests that there is a “right” and “wrong” way to eat and that if one follows their food rules, they will live a longer, healthier life. In a way, it kind of smacks of orthorexia (i.e., an obsession with eating in a “perfect” manner) to me, which is tricky, as a number of people want to eat “correctly” and view food simply as fuel for our bodies that should always be of the highest nutrient value. It’s not a bad thing to want to eat healthfully and reap the benefits, but I firmly believe that flexibility is key to developing a healthy relationship with food and one’s body. Eating Oreo cookies is not a death sentence, and eating fruits and vegetables will not necessarily lead to you avoiding dying from cancer. What matters is the overall makeup of our diets, recognizing that all foods fit and that sometimes cookies are the right choice in certain situations.

Diets are seductive – they make lots of promises about how you are going to feel, how your body will change, and how your health will improve. They tell you that by following this arbitrary set of rules, you will reach true nutrition nirvana, all of your ailments will subside, and you will become the best version of yourself. Unfortunately, this is rarely the case, and most people cannot follow such strict guidelines for more than a short while, leading them to backlash by eating all of the “forbidden” foods and feeling like a failure. The very nature of diets is temporary, and any results one experiences during the “honeymoon” phase of a diet will likely dissipate once the dieter cannot follow the plan anymore.

I discourage my patients recovering from EDs from trying a plan like Whole30. In my work with these individuals, I am trying to help them eventually learn to trust their own bodies’ wisdom, that their body will tell them what, when, and how much to eat if they listen hard enough (i.e., intuitive eating). Eating in a way that is enforced by a set of external rules, like Whole30 or any other diet plan, flies directly in the face of this intuitive eating philosophy and can derail progress for many individuals dealing with ED. My advice? Skip the Whole30 and find an intuitive eating specialist who can help you rediscover what foods work for your body and promote your health (mentally, physically, and emotionally).

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.

He Said, She Said: Obesity Awareness Month

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He Said

The concept of National Childhood Obesity Awareness Month is flawed in several ways, many of which Joanne covers in her She Said passage. The most glaring issue, in my opinion, is that by promoting the use of weight as a proxy for health, the government is paradoxically distracting from matters of actual health.

Human beings can be healthy at a variety of weights, which is why we cannot draw accurate conclusions about someone’s health or behaviors based solely on their size. Thin folks can have plenty of medical woes. A couple of years ago, I wrote about a slender friend of mine who was diabetic, suffered a heart attack, and ultimately died of cancer. Someone might be thin due to food insecurity, a medical condition, psychological disturbances, eating disorders or disordered eating, or overexercise, just to name a few of the health-threatening issues that might lead to lowered body weight.

With a focus on obesity, not only do we miss an opportunity to identify and assist people at risk for or suffering from these problems, but we actually push them in the direction of trouble. For example, I have recently seen an increase in pediatric patients, including males, with eating disorders or disordered eating that reportedly stemmed from a fear of getting fat brought on by discussions at school or the doctor’s office.

One of my teenage patients recently told me how his pediatrician praised him for having lost weight from one annual checkup to the next after having chastised him the year before, but what his doctor did not know was that my patient had overexercised and restricted his food intake leading up to the appointment for fear that his doctor would again be mad at him if he had not lost weight. My patient’s behaviors brought him further away from health, not towards it, and the poor communication between him and his doctor puts him at risk for improper care in the future. Furthermore, food restriction elevates his risk for binge eating disorder and, ironically, ultimate weight gain.

Trust me, children who are obese already know it. They hear about it on the playground, in gym class, on television, online, maybe in the pediatrician’s office, and from other sources that tell them something is wrong with their bodies and it is their fault. National Childhood Obesity Awareness Month calls even more attention to them and their bodies, thereby exacerbating stigmatization and bullying.

The concept of National Childhood Obesity Awareness Month may be well intentioned, but its fallout is the exact opposite of the desired effect. If we want to improve the actual health of our children, better to promote size diversity and the importance of healthy behaviors, such as fun and appropriate physical activity, for everybody.

 

She Said

According to the U.S. Department of Health and Human Services (HHS), September is National Childhood Obesity Awareness Month. Per the HHS website, “one in 3 children in the United States are overweight and obese,” putting kids at risk for developing health problems such as type 2 diabetes, hypertension, and heart disease. The website goes on to say that childhood obesity is preventable, as “communities, health professionals, and families can work together to create opportunities for kids to eat healthier and get more active.” Some of the strategies that the HHS recommends are nutrition based, such as “keeping fresh fruit within reach” and providing healthier food options at school, and other strategies are focused on activity levels, such as encouraging families to go on an after-dinner walk and incorporating daily physical activity at school.

While I actually applaud the strategies put forth by the HHS to improve kids’ health, I am saddened to see the focus be on body size. Thanks to Michelle Obama, childhood obesity is at the forefront of the American consciousness. Kids are being weighed and measured at school and then later sent home with a health report card telling them whether they are at a “healthy” body mass index (BMI) or are in the “overweight” or “obese” categories. Even though the medical community as a whole willingly acknowledges that the BMI is woefully flawed as an indicator of health status, it still condones its use in determining the health of our kids. Time and time again, studies have shown that behaviors rather than weight are a better determinant of health, but unfortunately, this is not being reflected in current policy.

My greatest concern is the effect that focusing on childhood obesity could be setting up kids to develop eating disorders (EDs). I cannot tell you how many preteens who have stepped into my office had been sent home with their BMI report card and then developed either extremely disordered eating or an actual diagnosable ED. What often happens is that the parents become alarmed at their child’s negative BMI report and will start to impose harsh diet restrictions and exercise ultimatums. I had one patient whose father promised her and her sister iPads if they both lost weight. Not only would he limit their access to “junk” food, he would make them run laps around their neighborhood after dinner every night. As a result of this, the patient developed a very disordered relationship with food and her body. This story is not unique, unfortunately. I have heard it too many times to count.

So, I have a few issues with the HHS’s focus on obesity. First of all, I don’t believe that we should have schools be weighing and measuring kids and sending them home with a BMI report card. Instead, the child’s pediatrician and parents should be the gatekeepers of the child’s health. Every child has their own unique growth charts – some trend on the higher end of weight for height, while others trend on the lower end of the chart. In other words, some kids are just meant to be in bigger bodies, while others are meant to be in smaller bodies. These body sizes do not tell us anything about the child’s health unless there are major changes in either direction. For instance, one would expect a child trending on the 85th percentile to stay at that percentile. If there was a sharp drop to the 50th percentile, that would be cause for concern. Similarly, if a child was trending on the 50th percentile and then jumped up to the 90th percentile, that should also be looked at. One body type is not inherently healthier than the other – every body is unique.

In addition, I think it is so important to not speak negatively about a child’s weight. Kids are like sponges, and they pick up on everything. Talking with one’s child about how their body works and teaching them how to take care of it is one thing, but telling a child that they are too big and need to lose weight is extremely damaging and can set the child up for years of negative body image and a life of disordered eating. Many EDs start when a well-meaning parent tries to teach their child to diet and use exercise to burn calories. In fact, there are a number of studies that show that when children are put on restricted diets, they will often end up being heavier adults.

Also, I think that if a parent has concerns about his or her child’s weight, they should talk with their child’s pediatrician separately (i.e., not with the child in the room). Instead of telling the parent that their child simply needs to lose weight, it would be wonderful if pediatricians did not just make an assumption based solely on the child’s weight that the child is engaging in unhealthy behaviors. If it is determined that the child is in fact not practicing healthy lifestyle behaviors, it would be best if the doctor just focused on helping the child develop these healthy habits (perhaps by referring them to a registered dietitian or other health care provider) and measure the child’s progress by their weight.

Given that, I don’t think that National Childhood Obesity Awareness Month is helpful at all in helping our kids lead healthier lives. By teaching them that weight is synonymous with health, we are doing them a major disservice. Perhaps September could instead be called National Healthy Habits Awareness Month? Just a thought.

He Said, She Said: My Big Fat Fabulous Life

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In a recent episode, of My Big Fat Fabulous Life, the protagonist visits her alma mater where she gives a talk about body positivity and then fields questions from students. Who knows what really went on in that auditorium, but if we take the video at face value, she did a fine job of responding, especially for a layman who was put on the spot. With time and expertise on our side, we took our own stabs at answering two of the questions that arose.

 

He Said

“The medical community actually agrees that obesity can lead to a shorter life span. Do you think that your No BS [No Body Shame] campaign, which emphasizes feeling confident and beautiful at any size, do you think that that can coexist along with the very real facts that they do cause legitimate health concerns?”

The premise of this question is faulty in a few different ways.

No, the medical community does not agree that obesity can lead to a shorter life span.

Research actually suggests that other factors have a greater impact on mortality than does body size. For example, a 2012 study by Matheson et al. looked at the impacts of consuming five or more fruits and vegetables daily, exercising regularly, consuming alcohol in moderation, and not smoking and found that mortality was virtually identical across all studied body mass index groups when subjects had all four healthy habits. In other words, when it comes to our risk of dying early, behaviors are a better predictor than is body size.

In his 2010 study, Fogelholm found that physically active obese individuals had better cardiovascular and all-cause mortality risk than sedentary “normal weight” people, again suggesting that when it comes to matters of life span, behavior is a more important factor than is body size.

The entire body of research is bigger than just two articles, and of course, not every study reaches the same conclusion, which reinforces how much we still have to learn and underscores how inaccurate claims of universal agreement within the medical community are regarding this complex topic.

Size acceptance and health are two separate issues.

“The mission of the No Body Shame campaign,” according to its website, “is to help every individual overcome the debilitating effects of societal-induced shame. Supporters of No Body Shame have named weight, height, skin color, sexual orientation, gender, different abilities, and specific physical attributes as causes of shame. Whitney believes that when we commit ourselves to living our best lives now, accepting ourselves as we are even if others do not accept us, real changes in confidence and quality of life are not only possible, but imminent.”

Note that nowhere in the mission statement does health appear. No BS is part of the size acceptance movement, which is related to, but not synonymous with, initiatives like Health at Every Size (HAES®) that promote a paradigm shift within the medical community to focus on actual health instead of weight.

In explaining size acceptance, Ragen Chastain writes, “Everybody deserves basic human respect and civil rights and that should never be up to show of hands or vote of any kind. Fat people have a right to exist, there are no other valid opinions about that. Our rights to life, liberty and the pursuit of happiness are not someone else’s to give, they are inalienable. SA [Size Acceptance] activism is not about asking someone to confer rights upon us but rather demanding that they stop trying to keep them from us through an inappropriate use of power.

HAES, on the other hand, can be succinctly encapsulated as a weight-neutral approach to health. The Association for Size Diversity and Health (ASDAH) elaborates by saying, “The framing for a HAES approach comes out of discussions among healthcare workers, consumers, and activists who reject both the use of weight, size, or BMI as proxies for health, and the myth that weight is a choice. The HAES model is an approach to both policy and individual decision-making. It addresses broad forces that support health, such as safe and affordable access. It also helps people find sustainable practices that support individual and community well-being.

While size acceptance and HAES are different concepts, clearly they relate. The situation is more complex than I am about to make it seem, but for the sake of brevity, consider how weight stigma pushes people into weight-loss pursuits that are most likely to worsen their health. If we as a society are more accepting of people of all sizes, we free each other up to instead focus on our actual health.

The implication that feeling unconfident or unbeautiful at certain sizes inspires better health is the exact opposite of what tends to actually happen.

Tomiyama and Mann conducted a study in which they posed two sets of questions to different subject groups. One set of questions was designed to make the subjects aware of weight stigma while the control questions asked about ecofriendly behaviors.

After subjects answered their questions, researchers presented them with a variety of foods and gave them permission to eat whatever and however much they would like. The people who had just responded to questions about weight stigma consumed significantly higher amounts of sugar and calories than those who answered neutral questions.

Their findings mirror our clinical observations and experiences. People often believe that self-dissatisfaction will somehow inspire better health, when in reality the individuals who love and accept themselves as they are tend to be the ones motivated to take better care of themselves.

Correlation is not synonymous with causation.

The questioner ended her inquiry with, “the very real facts that they do cause legitimate health concerns.” The context suggests that she misspoke when she used the word “they” and was actually referring to obesity.

If that presumption is indeed correct, then she is confusing correlation and causation. Earlier this month, I watched a fireworks display one evening and then a parade the next morning. Did the fireworks cause the parade, or did these events occur in close proximity to each other due to another factor, say, Independence Day?

Similarly, when we consider the diseases linked to obesity, we must remember that correlation does not equal causation. The link, in other words, might not be a causal relationship, but rather an association due to other factors. Many examples exist, but for the sake of brevity, consider just one: stress. Cardiovascular disease, which is often blamed on obesity, is also associated with life stress.

If you are not obese yourself, do your best to put yourself in those shoes for a moment: You live in a society where the government has declared war on your body size; where fat hate and bullying are prevalent online and in real life; where you might fear going to the doctor because you are more likely to receive a judgmental directive to lose weight rather than an actual evidence-based medical intervention; where commercials, memes, advertisements, talk at the gym, the grocery store, and over the dinner table hammer at you repeatedly throughout the day, every single day, that something is wrong with you and it is your fault. Tell me, how is your stress level?

 

She Said

“My father passed away this past April. He was severely overweight, he was diabetic, and he was an avoider, right. Do you think there is an ethical concern in folks who view you as a health and fitness expert or at least a public figure and use that body positivity message as an excuse to avoid actually addressing their real health concerns?”

While the second sentence of this audience member’s question is not a question at all, I think it needs to be addressed. Although he didn’t specifically say so, this statement reads as though the questioner believes that his father’s weight was to blame for the development of his type 2 diabetes (T2D). As we have discussed numerous times before, weight and health are two very different things and that while being “overweight” or “obese” might be correlated with certain health conditions, such as diabetes, there is no evidence that being “overweight” or “obese” causes these conditions.

In a 2012 interview for the Health at Every Size blog, author Linda Bacon explains, “while it’s true that the majority of people with T2D are in the BMI categories of ‘overweight’ or ‘obese,’ that’s at least in part because the insulin resistance that underlies most cases of T2D often causes people to gain weight. In fact, weight gain may actually be an early symptom—rather than a primary cause—of the path toward diabetes.” In addition, Bacon cites a “review of controlled weight-loss studies involving people with T2D” which showed that while “overweight” or “obese” individuals with T2D had initial improvements in their blood sugar levels with weight loss, those levels eventually returned to baseline within 6 to 18 months, even for those few individuals who had managed to keep the weight off.

I also think it is important to look at the way that the questioner described his dad: as an “avoider.” That tells me that this man believes that his father did not take care of himself to the extent he could have in order to have prevented his untimely death; that if his father had not “avoided” his health issues by presumably eating better and losing weight, he might still be here today. That seems like a very serious assumption. Sometimes even when people take all the right steps in dealing with their health condition, they will still pass away. We all like to think that if we eat perfectly, don’t smoke, don’t drink, and do all the “right things” (i.e., healthy life behaviors), we will live forever. Unfortunately, none of us is immortal.

Now to address the actual question that was asked. I find this question problematic for a couple of reasons. First, I don’t think that Whitney (the protagonist of MBFFL) has ever tried to portray herself as a “health and fitness expert.” Over the first 3 seasons, she has consulted with a registered dietitian who practices Health at Every Size® (HAES®), has seen a cardiologist, and has been working with a personal trainer in addition to other health professionals. She herself admits that she struggles with the health and fitness part of her life, particularly in that she battled an eating disorder for much of her teens and twenties. She has never presented herself as an expert in nutrition, fitness, or medicine.

The second reason I find the question problematic is that the questioner assumes that the message of body positivity is being used as an excuse for people of size to avoid dealing with their health issues. This is simply untrue. Body positivity is about seeing all bodies as “good” bodies, that no one body type is the “ideal,” regardless of what our society (particularly the media) likes to tell us. In other words, the body positivity movement says “there is no wrong way to have a body.” It also recognizes that “good health” is not a requirement to have a body and that sometimes (due to circumstances outside of one’s control) our bodies might not be healthy. This does not mean, however, that these bodies are any less good.

At the end of the day, I think the best way to think about this question is through the lens of the “Underpants Rule,” coined by the brilliant blogger Ragen Chastain of Dances with Fat. Ragen defines the rule as such: “everyone is the boss of their own underpants so you get to choose for you and other people get to choose from them and it’s not your job to tell other people what to do.” This means that others do not have a right to tell you how you should take care of your body and vice versa. Whitney has never told her viewers (at least to my knowledge) how they should be treating their health conditions – she is only focusing on her own body and health issues.

Body positivity does not assume that everyone is actively trying to be living their healthiest life. It is more about helping people realize that skinny bodies are not the only bodies that are worthy or beautiful. Yes, some individuals might show love for their bodies by trying to take care of them by eating a varied, nutritious diet, being physically active in an enjoyable way, getting enough sleep, and managing stress. But not everyone is able to engage in all of these behaviors. The body positivity movement says that even if one is not in the best of health, their body is still valuable.

He Said, She Said: Parents

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WorldEDDay

He Said

June 2nd was World Eating Disorders Action Day, which was an important occasion that helped to cast desperately needed light on these conditions that are so common, yet receive so little attention.

Many of our colleagues shared articles, blog posts, and memes on social media to commemorate the day. One particular meme caught my attention because it read in part, “Families are not to blame, and can be the patients’ and providers’ best allies in treatment.”

To be candid, that statement is only partially true. On one hand, eating disorders can certainly arise in the midst of even the most loving and supportive family dynamics. On the other hand, environment is an important factor in the development of eating disorders, and this broad term that encompasses television, social media, print media, teachers, friends, coaches, co-workers, and many other influences also includes family.

Neither Joanne nor myself is here to pass judgment on anybody. Parenting is hard work, and all of us, parents and otherwise, make mistakes sometimes despite our best intentions. If we are to help families become the supportive allies that the meme correctly states they can be, then we must acknowledge the reality that even well-meaning and loving parents sometimes inadvertently contribute to the problem.

This month, Joanne and I discuss some of the most common mistakes parents make that can promote or exacerbate an eating disorder or otherwise hinder their child’s nutrition care, and we suggest alternative behaviors that can be more helpful. Joanne tackles the behaviors most related to eating disorders while I address others that I see in my side of the practice, although overlap certainly exists between the two.

Mistake 1: Modeling disordered behavior

“I can’t do moderation,” one of my patients insisted. She was 12 years old. With both of her parents out of the room, she explained to me how her parents oscillate between restriction and overconsumption. The former might take the shape of cleanses, clearing the house of “junk food,” enrolling in weight-loss programs, or other similar actions, while the latter might manifest itself through binges, lamenting their eating behaviors, or expressing concerns about a food “addiction” or feeling out of control.

The patient in question was well aware when one of her parents was about to transition from one state to another. “You cracked the seal!” her mother reportedly exclaims to her father (or vice versa) when a “bad” food is brought into the house. Because this is the behavior modeled in my patient’s household, no wonder she similarly feels, at such a young age, already destined for and incapable of anything beyond an all-or-nothing relationship with food as well.

Improvement: Model a healthy relationship with food

Children often learn through observation. Family meals in particular are an excellent time for parents to model their healthy relationship with food. Serve and consume a wide variety of foods. Destroy the good/bad food dichotomy by incorporating “bad” foods and showing that one is neither guilty for having them nor virtuous for sticking solely to “good” foods.

Similarly, keep a wide variety of foods in the house, as attempts to restrict the food supply typically backfire sooner or later. Children are bound to encounter “bad” food at friends’ houses, camp, and other environments, so better to help them build a healthy relationship with these foods early in life before they grow into young adults who do not know how to handle the newfound freedom that accompanies all-you-can-eat college dining halls.

In order to model a healthy relationship with food, parents must first of all have one. Be candid with yourself and realize that the best way to help your child might be to recognize and seek help and support for your own eating issues.

Mistake 2: Putting too much responsibility on the child

Encouraging autonomy and empowering children have their upsides, but parents sometimes take these actions too far. They step so far back that children are left without the parental support that they need to succeed. Parents might leave their children alone with us for more time than would be ideal, decline invitations to meet with us without the children or to check in with us between sessions, opt not to reinforce at home the ideas we discuss in session, or fail to implement action steps that necessitate parental involvement.

Improvement: Work together as a team

Just as children of all ages look to their parents for a variety of resources, everything from physical needs to unconditional love, they need similar help with their nutrition. Children have their own feeding responsibilities, but so do parents. In order to suss out who is responsible for what, parents must actively participate in the process. Initially, parents may not see eye to eye with us or have questions or concerns about our approach, and these thoughts are best expressed in private so as not to confuse the child with conflicting paradigms. In short, working together as a team tends to yield the most fruitful results.

Mistake 3: Assuming their children can lose weight because they did it themselves

Many of the children at our practice have parents who are high achievers. Through hard work, discipline, sacrifice, and other life choices and factors, they have reached the pinnacle of their respective fields. Some of these parents have applied these same traits to their own weight-loss endeavors with similar results. They assume that if their children take a similar path, they will reach the same outcome.

Improvement: Differentiate between typical and atypical results

If you have lost weight and kept it off, recognize that you are the exception, not the rule. Approximately 95% of people who attempt to lose weight will regain it one to five years down the road, and roughly 60% of these individuals will end up heavier than they were at baseline. Weight regain is common even if someone maintains the behaviors that promoted the weight loss in the first place.

Contrary to popular myth, our weight is largely out of our hands. The calories-in-versus-calories-out paradigm is a gross oversimplification of the complexities affecting weight regulation. While we might be able to manipulate our body size through behavior changes for a short while, biological mechanisms promoting weight regain almost always win out in the end.

Even genetics and behaviors together do not tell the whole story. For every Griffey or Boone family, we have hundreds of major league ballplayers whose offspring will never make it in the pros. Set aside the notion that what worked for parents will work for a child, and accept that your child may never lose weight and keep it off no matter what he or she does.

Mistake 4: Encouraging weight loss

A desire to lose weight leads to dieting, which is a predictor for eating disorders, worse health, and ultimate weight gain. Parents may understand the dangers and futility of dieting and instead encourage “lifestyle change.” Unbeknownst to them, the behaviors they have in mind, such as restricting calories or certain food groups, keeping a food journal, weighing or measuring portions, or staving off hunger by filling up on liquids or low-calorie foods, are still tricks of the dieting trade. Different packaging, but same contents.

Improvement: Promote size acceptance

Weight stigma is real and widespread. Children encounter it on the playground, on television, on social media, in the classroom, and maybe even at the pediatrician’s office, but they do not have to face it at home. Promote size acceptance and discuss the stigma they inevitably bump into as they move about the world. An additional and important lesson: Teach them not to contribute to said stigma.

Mistake 5: Talking about “health” as a euphemism for “weight”

Sometimes parents have a sense of the dangers associated with focusing on a child’s weight, so they substitute in the word “health” instead. Children are perceptive, however, and they learn about our cultural obsession with weight and size at an early age. When their parents say, “I just want you to be healthy,” they interpret this in context and hear, “I just want you to lose weight.” When they start talking to the big kid in the family about “health” and bring him to a dietitian while his skinnier siblings receive no such treatment, trust me, he knows exactly what is going on.

Improvement: Recognize that health and weight are not synonymous

Health and weight are not nearly as synonymous as we have been led to believe. Studies have shown that weight loss does not automatically lead to better health, and other research that controlled for behaviors found that health risks between groups of people of different body weights were nearly identical when engaging in similar behaviors. If health itself is indeed the priority, then apply it to everyone in the family, regardless of body size.

 

She Said

June 2nd was World Eating Disorders Action Day, during which numerous organizations and activists all over the world brought to light the prevalence of eating disorders (ED) and the need for comprehensive treatment. Jonah and I noticed a meme that was circulating on that day which outlined nine facts about EDs. While overall I felt like the meme was accurate and could be quite helpful for those unfamiliar with EDs, I felt like one of the “truths” was not completely accurate. This “truth” states, “Families are not to blame, and can be the patients’ and providers’ best allies in treatment.” My issue does not lie with the second part of the sentence, as I fully believe that parents can be wonderful allies in helping someone recover from an ED. But I do not agree with the statement that families are not to blame.

Let me be clear: I am not saying that it is solely the parents’ fault if their child develops an ED. But absolving parents of any blame doesn’t ring true to me.  As in most diseases, genetics play a large role as does environment. One way of thinking about it is this saying: “Genetics load the gun, but environment pulls the trigger.” Well, parents are part of the child’s environment, and therefore they can contribute (even unwittingly) to the development of their child’s ED.

99% of the time, parents are acting out of love for their child. They don’t want their child to suffer and only hope that he or she will be happy and healthy. But even with the best intentions, sometimes parents (and other family members) can inadvertently trigger an ED in a genetically predisposed patient. The following are some examples of how this can occur:

Example #1: The parent speaks negatively about his or her own body.

This might be surprising to some people, but children of parents who speak disparagingly about their own bodies (i.e., not their child’s body) are more likely to develop issues with eating and body image. I’ve had numerous patients whose parents only tell the patient how beautiful/handsome/perfect he or she is, or that there is nothing wrong with the child’s body. However, oftentimes the child will overhear their parent complaining about their own “love handles,” saggy body parts, or “unsightly bulges,” and even though these comments aren’t directed at the child, he or she learns to internalize these messages and can start to believe that his or her body is “wrong” too. The best way to prevent this from happening is for parents to avoid negatively talking about their own bodies, especially in the presence of their child. All bodies are good bodies, and stressing this message can help kids develop a more positive body image.

Example #2: The parent puts too much responsibility on the child and does not take an active role in his or her ED recovery.

Sometimes I encounter parents who want to take a step back from their child’s ED, as they believe that the child should be in charge of his or her recovery. While I agree that the patient needs to take an active role, most kids are dependent on their parents for food, as parents are the ones who go grocery shopping and who do the meal prep and planning. A child who is dealing with an ED cannot be counted on to feed himself or herself appropriately. Very few kids with EDs take the initiative to prepare a snack or meal for themselves. I had one patient that often would skip meals and snacks because she knew that her parents weren’t watching her. My advice would be that parents need to take an active role in their child’s ED recovery, especially if that child is a younger teenager. This means that parents might need to supervise meals and snacks, make sure that there are ample and appropriate food choices in the house, and hold the child accountable for food eaten outside of the house. Regarding the latter, signs may suggest that a child is not following her meal plan while at school, for example. In such instances, parents have the responsibility to arrange for a teacher or school nurse to supervise the child’s eating to ensure compliance with the meal plan.

Example #3: The parent encourages their child to lose weight.

This is a tough one. In our fatphobic and fearmongering culture, being overweight or obese is seen as a terrible fate. With the help of Michelle Obama, every parent is vigilant about their child becoming a part of the “childhood obesity epidemic.” Even if a parent feels like their child is “fine,” pediatricians can scare parents into seeing their child’s weight as a ticking time bomb. I’ve had too many patients to count whose parents bring them in because their doctor wants the child to lose weight. In some cases, these kids are encouraged to go on diets, and they receive praise for every pound lost. I had one patient in particular whose parents promised her a new iPad if she lost a certain amount of weight. Obviously, I feel that encouraging one’s child to lose weight is very problematic. Study after study has shown that kids who start dieting from an early age are actually more likely to become overweight or obese in adulthood. In other words, the end result is the exact opposite of what these parents are hoping for. My best advice is to stop focusing on your child’s weight. Instead, focus on his or her health, as we know that health and weight are not necessarily synonymous. Also, I would recommend talking with the child’s pediatrician (without the child present) to discuss taking the focus off the child’s weight, as negative messages about the child’s weight can lead to a preoccupation with food and even development of an ED.

Thus, while I really agree overall with the “truths” outlined by the meme, I would modify #2 to say that family dynamics can play a role in the development of an ED. While it is true that parents are not solely to blame for their child developing an ED, they can use some of the above strategies to make it less likely that their child will go down that treacherous path.

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.

He Said, She Said: “I want to lose weight”

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He Said

When faced with “I’ve got some good news and some bad news,” most people seemingly prefer to hear the latter first. With that in mind, let us first look at the results of weight loss pursuits before coming around to the opportunities we have for change.

Short-term and long-term weight loss are two entirely different animals. The ease with which short-term weight loss is promoted creates false expectations for long-term weight loss. Pretty much any kind of restriction (Paleo, Weight Watchers, gluten-free, low-carb, low-fat, weighing/measuring portions, following a scripted meal plan, commercial meal substitutes, etc.) performs about the same: initial weight loss followed by regain that often surpasses the baseline weight. The overall body of research suggests that pursuit of intentional weight loss is approximately 12 times more likely to result in ultimate weight gain rather than loss.

The patients who come to me looking to lose weight often have similar stories. They list the various diets they have tried over the years before disclosing “and now I am the heaviest I have ever been in my whole life.” Frequently, they look back on their body size and shape from before the first diet, the body they were unhappy with at the time, with a new longing, like an empty-handed gambler wishing he had put his coins to better use rather than wasting them in the slot machine.

While their reasons for wanting to lose weight vary, they are all valid and understandable in the context of our society in which weight stigma, size discrimination, diet culture, and misinformation are so prevalent. These unfortunate realities bleed into our healthcare system and can influence otherwise-great doctors to recommend weight loss rather than evidence-based treatments.

The good news is that the underlying reasons for wanting to lose weight are oftentimes attainable if we pursue them directly rather than using weight loss as a proxy. Whether your goal is to improve your blood pressure, lower your cholesterol, control your blood sugar, perform your sport better, our build a fabulous wardrobe, or anything else along those lines, your likelihood of success is much higher if you put weight to the side and go for your goal head-on.

 

She Said

Weight is a heavy topic (pun intended) in my work with eating disorders. Even though I put a lot of effort into making sure that weight is not the focus of my work with patients, inevitably, it will come up. Usually, my patients express fear around the possibility of gaining weight by eating intuitively (or by following a meal plan). In addition to this fear of weight gain, many of my patients also desperately want to lose weight. When the patient is in the “overweight” or “obese” BMI category (a completely bogus way of measuring one’s health), the discussion of losing weight is particularly tricky. Oftentimes this patient will come into my office with a recommendation from their doctor to lose 10% of their body weight in order to improve their health. This, coupled with society’s belief that “everybody knows that being heavy is unhealthy,” also complicates matters considerably.

When a patient comes to see me with hopes that I will help him or her lose weight, I often feel like the Grinch. As I try to explain to them that weight is not a measure of health, that one can be heavy and healthy (or thin and unhealthy), and that society’s fear and hatred of fat is a real thing, I can see their eyes glaze over. And then, when I talk about how 95-98% of all intentional weight loss attempts (via diets) result in weight regain, sometimes I can see panic in their eyes. You see, even though “everybody knows” that diets don’t work, many people believe that if they just try hard enough and if they really, really want it, they can be part of that 2-5%.

As Jonah and I have written about too many times to count, we practice from a Health at Every Size® (HAES) perspective. This means that we believe that health is a multifactor concept that cannot just be boiled down to how much someone weighs. We believe that when someone eats in a nourishing, pleasurable, and intuitive way, when someone engages in physical activity that feels good to their body, when they manage their stress, get enough sleep, avoid smoking, manage health conditions with the help of a health professional, etc., that they can achieve health regardless of what the scale says. Weight only gives us a tiny bit of information about the person. It can tell us something is amiss if there is a large shift either up or down (unintentional weight gain or loss), but otherwise, by itself, it really cannot tell us if someone is healthy.

Another thing I talk about with my patients is that bodies are supposed to come in all shapes and sizes. Even though our society might disagree, some people are just meant to be larger than others. It’s in our genes. We all have a set weight range where our weight would naturally settle in if we ate and moved intuitively. While we might have some ability to move up or down a couple of pounds within this weight range, trying to go outside this weight range takes extreme measures. Our bodies fight these extreme measures in every way possible, but for 95-98% of us, we will return to our set weight range, regardless of whether or not we continue dieting.

But in our society, being heavy is seen as a weakness in someone’s character, that he or she is lazy, undisciplined, and reckless with their health. People make assumptions about others based on their weight, and it seriously stinks. So when an “overweight” or “obese” patient comes into my office desperately wanting to lose weight, I get it. No one wants to be seen as lazy, weak-willed, or stupid. My hope is that someday soon society’s views about weight will shift and that people will start to understand that we all have different genetic makeups, and that while weight can tell us what our relationship with gravity is, it cannot tell us whether someone is healthy, happy, or worthy.

He Said, She Said: Weight Loss for Athletics

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He Said

“You’re an RD, right?” That’s what one of my patients asked me last year shortly before he got up from the table and walked out of my office, never to return. It was more of a rhetorical question, really, his polite way of telling me I don’t know how to do my job.

He and I were only in each other’s lives briefly, as that was not only his last visit, it was also his first. His new patient paperwork stated that he wanted to lose weight in order to complete a marathon. Upon reading that, I contacted him in advance of his visit and offered a heads-up that I would help him to run his best, and as a consequence of doing so, he might also lose weight; but I would not be helping him to lose weight in hopes that it would improve his running because – contrary to popular belief – that is not how things actually work.

Although I suspected he would respond by cancelling the appointment, to his credit he had an open enough mind to meet with me and discuss our different points of view. Elite marathon runners are all very skinny, he told me, so it only seemed logical to him that if he could alter his body to look more like theirs, then he would in turn become a better runner.

Way back in my sophomore year of high school, I held the same belief. When I looked at those teammates on my track team who were faster than me, I noticed that for the most part they were leaner than me. Consequently, I attempted to change my body by restricting my fat intake (Back in those days, people were scared of fats the same way people nowadays fear “carbs.”) in hopes that I would also run better.

In fact, I ran worse. My mom took me to a dietitian who educated me, dispelled some of the nutrition myths that I held, and convinced me to increase my fat intake. My times in all events dropped, and I was the fastest I had ever been in my young running career without my physique ever changing all that much.

Having a leaner, smaller, or lighter body can certainly have athletic upsides sometimes, just as having a heavier or larger body can sometimes be advantageous, and I am not arguing otherwise. However, a significant difference exists between an athlete who naturally has a given size or shape versus someone who tries to force his or her body into that mold. That is where so many people, like my 15-year-old self and the patient I mentioned earlier, get tripped up.

Anecdotally, we see many examples of athletes who perform worse after intentionally losing weight. Last month, I wrote about how CC Sabathia has struggled since cutting his carbohydrates in an effort to lose weight. He and his slender frame are in the midst of experiencing the two worst seasons of his career, both of which have come since he lost weight.

Sabathia gave an interview earlier this year in which he talked about the fatigue he now experiences. Carbohydrates are our main source of energy. Now that he follows a low-carbohydrate diet, no wonder he currently tires early in games now. Only twice in my life have I failed to complete bicycle routes that I set out to ride. The first was when I fell off my bike in Montana and fractured my back. The other was when I was briefly experimenting with a low-carbohydrate diet and did not have the fuel necessary to make it home.

This summer, I had a couple of rowers come to me hoping to lose weight so they could compete in lightweight crew. Each of them believed that if he could shed enough weight to just make the 160-pound cutoff, he would dominate. However, they were not taking into account that the processes necessary to alter their bodies (over-exercise and/or dietary restriction) were likely to leave them unable to put forth optimal performances. A well-nourished and properly-trained 159-pound athlete is probably going to row much better than his or her 159-pound teammate who maintains that weight by existing in a state of depletion.

At the same time, let us acknowledge that not every athlete is already at the weight at which they can perform his or her best. Some athletes, just like the rest of the population, are subject to behaviors, such as emotional overeating, that might be impacting weight. However, putting the horse before the cart means directly addressing issues that might be hindering performance while allowing weight change to naturally occur or not occur as a consequence. To try losing weight in hopes of becoming a better athlete though is to have the process backwards.

 

She Said

Some of the individuals who come to see me for nutrition counseling are student athletes who are struggling with an eating disorder (ED). These cases are particularly challenging, as one of the cruxes of being an athlete (at least at a competitive high school or college level) is making sure one is in top physical condition to succeed in one’s sport. While this desire to be in the best athletic condition might be approached in a healthy and manageable way by some individuals, for those who are predisposed to EDs, it can sometimes start, trigger, and/or worsen the individual’s ED.

In the sports where weight control is believed to be paramount to success (e.g., gymnastics, ballet, track and field, etc.), this focus and, in some cases, obsession with being “lean,” “fit,” or “cut,” can result in the athlete eating in a restrictive manner (e.g., cutting out carbohydrates, only eating vegetables and protein) and exercising excessively. Initially, these individuals seem to be doing the right thing, taking care of themselves and making the sacrifices needed to become the best at their sport. The problem arises when the obsession with weight, food, and exercise takes over the athlete’s life. Examples of this include avoiding social situations that involve eating in order to train harder at the gym, exercising even while injured or sick, and panicking when being faced with foods that are not on the “clean eating” food list.

While these scenarios are red flags in and of themselves, the physical ramifications of these behaviors are serious as well. One of the most common outcomes that results from overtraining and undereating in female athletes is the Female Athlete Triad. This syndrome is characterized by three conditions: energy deficiency with or without a diagnosed ED, menstrual disturbances or absence of period completely (amenorrhea), and loss of bone density resulting in osteopenia or osteoporosis. In a nutshell, when an athlete is not eating enough to fuel her training, this can lead to dangerous health problems.

Some health professionals believe that individuals who are dealing with the above problems can continue to participate in their sports as long as they are getting nutrition education from a registered dietitian and having regular check-ups with their primary care physician to make sure they are medically stable enough to compete. While I agree that for some individuals it is just a matter of education and monitoring, for those with EDs, allowing them to continue with their sport could greatly hinder the recovery process. An ED is a multifaceted problem that needs a full treatment team including a therapist, dietitian, and doctor who is knowledgeable about EDs. The focus should be on helping the athlete become physically healthy while dealing with the underlying psychological issues that are part of the ED.

When I am working with a student athlete who is exhibiting disordered eating and/or excessive exercise, I always defer to the physician on the treatment team to make the call about whether the patient is medically safe enough to participate in his or her sport. The work I do with the patient centers on helping them understand what their body’s needs are fuel-wise. This might include educating the patient about carbohydrates and why they are a necessary macronutrient (for athletes and non-athletes) and how to eat to improve one’s athletic performance.

If you or someone you know seems to be struggling with an ED related to being an athlete, it’s important to take action. Talk to your doctor as soon as possible to prevent the situation from becoming worse. Find a therapist and a dietitian who are adept at working with athletes who struggle with EDs. It is also important to alert the sports team’s trainer and coach to the problem, as they will be an integral part of the treatment team. When all of these pieces of the treatment team are in place, the likelihood of recovery is much higher.