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.

He Said, She Said: Celebrity Diets

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He Said

In an interview with ESPN at last month’s Major League Baseball All-Star Game, Mark Teixeira, first baseman for the New York Yankees, fielded questions about the gluten-free, dairy-free, sugar-free diet he has reportedly been following since the off-season. Although he nicknamed his set of food rules the “no fun diet,” Teixeira praised his diet for bringing about his return to health and all-star-worthy performance based on his belief that the foods he had eliminated are inflammatory to the body.

Each time an athlete speaks up about his or her fad diet and its associated pseudoscience, life gets a little bit harder for the rest of us. Already, so much of my time with patients focuses on reeducation involving the food myths and misinformation that are so prevalent in our society. The Teixeira interview and others like it add fuel to the fire.

The problem is not that Teixeira has excluded gluten, dairy, and sugar from his diet. This is his body, his career, and his life, and I am in no position to judge him for the choices he makes regarding these entities or for whatever he believes, accurate or otherwise, about food. We all get to decide for ourselves how we want to lead our lives and what we want to believe, and he is subject to the same freedom.

Rather, the problem is how the dietary choices of athletes are framed and conveyed to the rest of us, the incorrect information and insinuations that often come along for the ride, and the bizarre phenomenon existing in our society whereby we put more stock in health advice doled out by celebrities than actual licensed healthcare professionals.

As a general theme, people tend to be more vocal about their dietary successes than their disappointments, which gives us a warped view of reality. Teixeira is not at fault for discussing his diet at the All-Star Game, not when the interviewers made a point to ask him about it. But would his diet be the subject of such conversation if his year was not going so well?

Consider his teammate, CC Sabathia, who lost a bunch of weight (temporarily, at least) after adopting a low-carbohydrate diet a couple of years ago. His diet and its associated weight loss got plenty of media attention back then, but hardly anybody seems to be talking about it now. Perhaps ESPN would have asked Sabathia about his diet at the All-Star Game if he was invited to be there, but as it turns out, he is in the midst of the second worst statistical season of his 15-year career, both of which have come after he went low-carb.

Did cutting carbs and losing weight cause Sabathia’s career to suffer? Possibly, but neither you nor I know for sure. While a correlation certainly exists, causation remains a question mark. Nutrition definitely impacts sports performance, but so does a host of other factors. Regarding Sabathia, elements like age, injury history, and general wear and tear are at play as well, not just his eating and weight.

Just as we cannot scapegoat Sabathia’s diet and lost weight for his poor play, we cannot automatically credit Teixeira’s newfound food rules for his bounce-back season. Perhaps he is simply healthy again for the first time in a long while after undergoing wrist surgery a couple of years ago. After all, except for 2013 and 2014 when he was injured, Teixeira has been one of baseball’s best players for over a decade, and it sure sounds like he was eating gluten, dairy, and sugar during all those years of dominance earlier in his career.

We see these same themes in other sports as well. A televised Novak Djokovic tennis match cannot go by without the commentators throwing in at least one mention of his gluten-free diet, which he credits for catapulting him to the status of number one player in the world. Yet, never once have I heard anybody in the media talk about the eating habits of Roger Federer, arguably the best player in the history of the sport and someone who has continued to compete at an elite level at an age well past when most tennis professionals retire. His diet consists largely of foods like cereal, pancakes, and pasta – in other words, plenty of gluten.

Could it be that Djokovic’s career took off not so much because he cut out gluten, but rather because his years of training, practice, and experience have come together during the window of prime age for a tennis player to produce great results? Similarly, perhaps Federer’s longevity, ability to stay healthy, and years of domination have less to do with pancakes and syrup and are more due to talent, hard work, smart coaching, and efficient mechanics.

If you find yourself tempted to adopt a fad diet because a successful athlete is preaching it, look at the big picture and remember that most of his or her peers are probably not following his or her diet and are also doing quite well for themselves, but their eating patterns are not as sensational and therefore not garnering the same attention.

On a more macroscopic level, challenge yourself to consider how much sense it really makes to be taking nutrition cues from an athlete or any other celebrity. My computer and telephone are essential for my work as a dietitian, and I use them daily, but I only know how to use what I believe works best for me. It would be a mistake to fancy me an IT expert, assume that I really know what I am doing in that regard, and emulate my choices. Similarly, looking to professional athletes and other celebrities as you shape your own eating makes little sense either.

 

She Said

About two months ago, there was a big buzz on the Internet (and news media) that superstar songstress/actress/business mogul Beyoncé had an “amazing” announcement to share with everyone. The plan was for her to make this announcement to all of her fans on the Good Morning America TV show, and it was going to blow everyone away. Of course, the Internet was shivering with excitement. Could it be that Beyoncé and Jay-Z are having another baby? Does Bey have a new album coming out, and is she going out on tour? Has she discovered the cure for cancer? The suspense was killing everyone!

Well, it appears that all she had to tell us was that she has found the secret to losing weight (and keeping it off) and living a fabulously healthy life. How did she achieve this, you ask? Well, by following a diet, of course! Per its website, the “22-Day Revolution” diet is a “plant-based diet designed to create lifelong habits that will empower you to live a healthier lifestyle, to lose weight, or to reverse serious health concerns.” The diet’s author, “world-renowned exercise physiologist” Marco Borges, is on a mission to help his clients find “optimum wellness” by eating a completely vegan diet. According to Borges, by eating “nutrition-packed” vegan foods, people will be able to “transform their lives, bodies and habits.”

Ugh. Can we please just stop the insanity? Every time a new celebrity announces their latest and greatest diet discovery, it makes me cringe. Given that the majority of my patients are those that struggle with eating disorders (ED), I am fully aware that these diets can be the gateway to a life full of pain and suffering, as most EDs start when one decides to diet. Young girls are especially vulnerable to these celebrity diets because they often put these actresses, musicians, and models on an impossible pedestal. Even though most magazine images are photoshopped nowadays, most young girls are not aware of this and aspire to be as lean and slender as Gwyneth Paltrow or as fit and toned as Kate Hudson.

The fact of the matter is that celebrities are not like the rest of us – they are the minority, not the majority. Even if they did not diet like they do, I doubt that their physiques would be much different than they are now. It’s genetics, pure and simple, and they have “won” in the genetics lottery of life. So, even if you go low-carb like Gwen Stefani or Paleo like Megan Fox, it’s highly unlikely that you will end up looking like these celebrities.

These diets or “lifestyle changes” touted by celebs do much more damage than good. Not only do these diets tell us that we cannot trust our bodies’ hunger and fullness signals (and therefore need to follow food rules to be “healthy”), but they also give us a nearly impossible goal of looking like these celebrities if we eat like them. And if someone is predisposed to EDs, each new celebrity diet is like lighting a match and tossing it into a powder keg – nothing good will come from it.

My advice? Whenever you hear about a new celebrity diet that promises to help you lose weight and keep it off, turn back the clock, or magically cure your health condition, please change the channel, toss out the magazine, or click on another website. Celebrities don’t know what’s healthiest for you to eat – only your body knows that!

He Said, She Said: 1,500-Calorie Diet

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A patient sent Joanne the following email. “I overheard a coworker talking about food/calories/etc. and noted her saying, ‘We should all be on a 1,500-calorie diet as women.’ For some reason this really got to me and I normally don’t let these stupid comments affect me, especially when I know better. Thoughts?”

 

He Said

Yes, I do have thoughts about this, several in fact, but for the sake of time and space, I will leave aside tangential issues of practicing dietetics without a license (If someone without a medical license made a statement along the lines of, “As women, we should all be taking [insert name of a medication] daily,” would you be cool with that?) and the virtually-constant propagation of nutrition myths throughout our culture. Instead, let’s focus on just how incorrect this coworker’s assertion is.

Caloric needs are surprisingly difficult to determine. The most accurate method is direct calorimetry, which utilizes a metabolic chamber in which the subject occupies a compartment that measures the heat that he or she emits during whatever state of activity happens to be taking place at the time. Unless you enroll in a research study that involves one of these chambers, you will most likely never gain access to one in your lifetime.

Indirect calorimetry, which involves measuring oxygen and carbon dioxide intake and expulsion, respectively, is less invasive in some ways and easier to utilize. Large hospitals typically have metabolic carts that can perform such measurements in their research laboratories, and lesser models exist for office settings. The tradeoff, however, is accuracy, as even the best indirect calorimetry tools are a step down from direct calorimetry.

Next we have the Fitbits of the world, devices that use algorithms to estimate caloric needs based on a crude set of variables. Dietitians use similar equations sometimes as well, and when I do, I always stress to patients that the results are just rough estimates that cannot and should not be taken too literally.

These equations have numerous sources of error, such as the reliance on subjective measures of physical activity. Anybody can Google how many calories certain activities supposedly burn, but really these numbers are general rules of thumb at best. Running a mile burns 100 calories, we are told, but is this right? What about the size and body composition of the runner, or his or her mechanics? Does he or she have short, quick strides or long, less frequent steps? What about swings of the arms, point of contact between the foot and the ground, head bobbing, or any number of other factors that can influence the results?

One of my patients occasionally asks me how many calories one burns during sex. Unless you get two people to have intercourse in a metabolic chamber, who knows? Even then, the heat generated would pertain only to those unique individuals in that specific encounter, so what do you do, divide by two and make the assumptions that their efforts were equal and that these results apply at other times and to other people as well? Logistical hurdles and the countless variables involved make estimating caloric expenditure a guessing game not just for sex, but for pretty much any activity.

As a consequence, estimates of caloric needs are just that – estimates – and vary widely from person to person. My degree in mathematics reminds me that I like numbers as much as the next guy if not more, and I can certainly understand the appeal of having a short, sweet, and specific target for which to aim, but really the best method to determine your caloric needs is to set quantifiable data aside and look internally to your hunger and fullness signals. Despite all of the proliferating nutrition myths and overarching messages we are taught from childhood on that we cannot trust ourselves regarding food, our bodies are actually pretty good at telling us what and how much they need. We just need to relearn how to pay attention and trust those signals again.

 

She Said

Ahhh, the 1,500-calorie diet. It’s amazing how some arbitrary number has gotten stuck in the minds of so many people. 1,200 calories is also a popular number. Flip through any of your typical women’s health magazines and you are likely to read that all women should be consuming no more than 1,500 calories per day to be “healthy.” Unfortunately, there really is no such thing as the “perfect” number of calories for each and every person. 1,500 calories (or 1,200 calories or 1,750 calories) is a myth. It makes no sense to say that every woman should be on a 1,500-calorie diet; we all are unique human beings with unique needs.

As I tell my patients over and over – every body has different caloric needs. Age, height, weight, gender, muscle mass, and activity level are just some of the factors that can affect our calorie needs. Even the Mifflin-St. Jeor equation, the equation most often used by most dietitians to determine calorie needs, does not take into account all of these factors. Our caloric needs will vary over our lifespan for a number of reasons. Women who are pregnant or breastfeeding need many more calories, while as we age, we typically need fewer calories. Anyone who has lived with a teenager can attest to the fact that calorie needs go way up during adolescence! When someone is recovering from an injury, his or her caloric needs might be elevated. For instance, the caloric needs of burn patients can be as much as double what the “average” person’s needs are. The best way to figure out what your calorie needs are? Eat as you normally would. If you see no large shifts in your weight (think plus or minus five pounds), you are meeting your calorie needs!

When working with patients who struggle with eating disorders, I try to steer clear of talking about calories. Many of my patients have spent countless hours logging the calories they ate (and burned), and most of these patients would say that they were “obsessed” with doing so. I had one patient who would log her calories daily, and if she consumed more than 1,300 per day, she felt like she had “failed.” Another patient would try to stick to no more than 1,800 calories per day, and if she went over by just a few calories, she would binge because she had “blown it.”

Instead of talking about calories, I try to use the “exchange” system with my patients. Exchanges are groups of foods that have similar nutritional profiles. For instance, a carbohydrate exchange (sometimes called “grain” or “starch” exchange) contains approximately 15 grams of carbohydrate per serving. This might look like an average piece of bread, a ½ cup of cooked pasta or rice or ½ of a large potato. By using exchanges, we can take the focus off of calories and how we need to limit them and instead talk about making sure we get enough carbohydrates, protein, fats, vegetables, etc. Calories have a negative connotation for many of my patients, while exchanges feel a bit more abstract and neutral.

In short, instead of setting an arbitrary calorie goal for oneself, I think it would be much more beneficial to set other goals. Getting five fruits and vegetables per day, being physically active for 60 minutes per day, and eating intuitively would be much better goals (in my opinion) than making sure one never goes over 1,500 calories per day.

He Said, She Said: Marathon Nutrition

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He Said

When I made the decision to leave behind my career as a research analyst for the U.S. Department of Transportation, I began looking for jobs in healthcare and landed a position working on a clinical trial with a kinesiology professor.

Given her background and expertise in exercise science and her personal interest in athletics, I shared stories of my marathon experiences with her and happened to include that I preferred Coke to Gatorade during long runs. “Ugh, that’s the worst thing you could do!” she disgustedly told me. Actually, no, I had figured out through trial and error that my body best tolerated plain old Coca Cola Classic over any other liquid with which I experimented, so I would argue that drinking Coke was the best thing I could do for athletic performance.

Sometimes, quite often actually, approaches that seem most sensible on paper do not function the best in real life. That is why guidelines are nothing more than their name suggests and should not be treated as gospel. Guidelines are helpful because they give us a place to begin, but I always emphasize to runners the importance of experimenting with various nutrition approaches during training to determine which eating and drinking strategy functions best for them and therefore will be used on race day.

In truth, marathoners take all sorts of different approaches to fueling themselves before and during marathons. Gatorade and water are supplied to the masses at various points along the Boston Marathon route, but the elite runners skip those tables and have their own hydration stations where each of them has a custom-made concoction waiting for him or her in labeled bottles. Some runners, for example, drink flat, non-alcoholic beer. A friend of mine used to eat gummy bears during marathons. Another friend made it through the running portion of his Ironman triathlon by alternately consuming oranges and bananas. As for me, I ran most of my marathons fueled by Coke and pretzels.

When Joanne and I first began dating, I was in the midst of a demanding dietetic internship, and I dealt with the stress by going for long runs on the weekends. Although it was clear that she found my behavior a bit odd, only she could tell you which struck her as weirder: the fact that I chose to spend my Saturday afternoons going for 20-25 mile runs, or the fact that I spent my Saturday mornings driving around and stashing bottles of soda and bags of Oreos in various hiding places along my running route. Just because gels, goos, sports jelly beans, and salt tablets exist and work well for some athletes does not mean they will have everybody running their best.

Commonalities do exist among the various approaches that people take, such as the importance of replacing the carbohydrates, electrolytes, and fluids lost during running, but numerous methods of achieving these nutrition goals exist, and that is where the importance of individualization enters the paradigm. Therefore, when you see or hear of another runner taking a different approach to his or her nutrition than you take to yours, remember that multiple “right” answers exist, and stay true to what you know from experience works best for you. Remain confident: Your training, both the running itself and your nutrition experimentation, has gotten you this far, and it will get you to the finish line, too.

 

She Said

April is one of my favorite months of the year. The winter is over (At least it should be!), little green things start sprouting out of the ground, and the promise of warmer days is ahead. Having been born and raised in Massachusetts, I have also come to associate April with the Boston Marathon. As a little girl, I would walk down to Route 16 with my mom, and we would cheer on the runners as they jogged past us. I was always amazed at how these individuals could just go and go and go. And how many of them there were!

From time to time, the subject of marathon running comes up in my work with patients struggling with eating disorders. Many of my patients are exercise enthusiasts who often have to cut back (or completely avoid) exercise in the early stages of ED recovery. As the individual makes progress in his or her ED, the subject of when he/she can start to exercise again will often come up. Of course, when figuring out whether to clear a patient for exercise, the primary care physician really needs to make the final call. Often this means that the patient should be having his or her vital signs taken regularly, and if his or her blood pressure, heart rate, and weight are routinely found to be in the “healthy range” for a good period of time, he or she may be cleared for exercise.

The word “exercise” can have a number of different meanings depending on whom you talk to. For the average person, perhaps going for a 30-minute walk 3-4 times per week would be exercise. But more often than not, for the person dealing with an ED, exercise usually means much more intense activity for more extended periods of time. That’s where the marathon piece comes in. I have had a number of patients state that they would like to resume (or start) running, not with the intent of managing their weight, but to strive for some goals. Usually, it will start with training for a 5K race, then a 5-miler, then perhaps a 10K. In and of itself, these races aren’t a problem vis-a-vis eating disorder recovery as long as the individual is competing and training due to the love of running rather than trying to control weight.

Sometimes I will have a patient announce the plan to run a ½ marathon with the goal of running a full marathon eventually. This is where things can get a bit dicey. As anyone who has run a marathon can attest to, the act is not an easy one. Although I have never run one myself, I have had people tell me it’s a lot like childbirth – after a period of time, one “forgets” the physical agony and only remembers the joy of finishing. In reality, running a marathon takes a huge toll on the body and can be quite grueling. For someone whose body is recovering from a life-threatening ED, training for and running a marathon can put a lot of stress on an already stressed body.

In general, I would suggest that the individual really delve deep into why he or she wants to run a marathon. Is it for the thrill of accomplishment, to check something off on one’s bucket list? Or is it a sanctioned way to exercise excessively, “permitting” the individual to eat with abandon and maintain or lose weight? Personally, I believe that someone needs to be in recovery for a significant period of time before attempting such a demanding physical endeavor. That period of time depends on a number of factors: How long has the individual struggled with an ED, and how long has the individual been in recovery? Has he/she maintained a healthy weight, heart rate, and blood pressure for a significant period of time? Is the patient’s mindset healthy or weight-centered?

If the individual is determined to be healthy in mind and body and the treatment team supports it, I think someone in recovery from an ED could in fact train for and run a marathon. However, it would be advisable for this patient to continue to engage in regular therapy and see his or her doctor weekly to make sure his or her marathon goals aren’t interfering with continued ED recovery. In addition, this patient should consult with a registered dietitian who specializes in both EDs and sports nutrition to make sure that he/she is getting in the right amounts and types of fuel and hydration needed for running a marathon. As long as the above conditions are met, there is no reason why someone who has struggled with ED couldn’t run a marathon.

He Said, She Said: Supplements

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He Said

As both a practitioner and a patient myself, I support the idea that everybody should have the freedom to pursue the healthcare path that feels right to the individual in question. The same freedom, I believe, should also extend to practitioners to be able to offer the modes of care that meet their own standards of ethical practice.

Approaches often evolve in response to new education and research. Earlier in my career, I worked at a medical center where selling supplements to patients is a significant part of their way of doing business. As I learned more about the science behind supplements and about the industry itself, I grew increasingly uncomfortable with this approach. Because of that background, you will not find any supplements or products of any kind for sale at Soolman Nutrition and Wellness LLC.

During our sessions, the topic of supplementation does occasionally arise, usually brought up by patients who have heard or read that a particular supplement regimen may help with whatever conditions are ailing them. However, we must remember that supplement manufacturers are allowed to make whatever health claims they would like – well-founded or otherwise – on the bottle just so long as they also have the standard disclaimer, “These statements have not been evaluated by the Food and Drug Administration (FDA). This product is not intended to diagnose, treat, cure, or prevent any disease.”

In other words, the claims made on the bottle may be wildly inaccurate and have absolutely no credible research to support them, but the FDA does not have the power to intervene. Generally speaking, regulation within the supplement industry is reactionary, not proactive. Not only can manufacturers say whatever they want about their products, but they also do not have to prove their products are safe before they go to market. The FDA only steps in when a problem arises, as it did in the 1990s when people died from the anti-obesity supplement commonly known as fen-phen.

Furthermore, the FDA does not regulate the contents of supplements themselves, and oftentimes actual products do not contain what is listed on the bottle. Back in 2008, for example, I attended a talk during which a dietitian presented an independent research study that found that the hardly any of the tested protein powders contained the amount of protein advertised on the label. John Oliver, in his funny yet factual breakdown of the Dr. Oz debacle and the supplement industry in general, reveals that one in three supplements contains no trace of the plant advertised on the bottle. “If one in three milk bottles didn’t contain milk,” he says, “you might think twice about pouring the white mystery liquid all over your cereal.”

Even information regarding legitimate substances, such as vitamins, is skewed. Vitamins get their distinction because a deficiency in any one of them can cause a specific disease. For example, vitamin C deficiency causes scurvy, which is one of the reasons why the British navy began providing limes for their sailors in the 1800s. During Europe’s Industrial Revolution, children no longer received the same sunlight exposure as they did in generations past and consequently developed rickets, an indicator of vitamin D deficiency.

However, just because an adequate amount of a vitamin will prevent a deficiency-related disease does not mean that a benefit exists to taking excessive amounts. The United States Department of Agriculture’s Dietary Reference Intakes include tolerable upper intake levels, defined as “the highest level of daily nutrient intake that is likely to pose no risk of adverse health effects to almost all individuals in the general population,” for most vitamins, yet we can easily – and unknowingly – exceed these upper limits through supplementation.

For all of these reasons, unless a patient’s situation suggests the contrary, I recommend doing our best to get our nutrients through food first and only bringing in supplements when necessary. If it does look like a supplement is warranted, I suggest my patient run it by his or her primary care physician.

 

She Said

The topic of supplementation often comes up in my nutrition counseling sessions with patients and their families. Since I am not a medical prescriber, I always refer patients to their primary care physician when it comes to questions about supplements. While I usually suggest that patients try to receive most of their nutrients from actual food sources rather than pills or powders, there is some promising research on specific supplements that may help those struggling with eating disorders (EDs).

As one would guess, those struggling with EDs are usually deficient in many different nutrients due to extreme restriction and/or purging or laxative abuse, and this can compromise every organ in the body. These nutrient deficiencies can lead to a number of medical issues for the individual, including (but not limited to) osteoporosis, anemia, and heart and kidney problems.

Many supplements have been studied in their relation to EDs. For example, zinc supplementation has been linked to improvement in appetite, taste perception, and mood as well as enhanced weight restoration and menstruation in anorexic girls and women. Supplementation with essential fatty acids, specifically EPA and DHA, has also been found to aid in weight restoration while decreasing preoccupation with and anxiety around food in those with anorexia. For those struggling with bulimia, supplementation with electrolytes such as potassium and magnesium is often prescribed due to the large amount of electrolytes that are lost through purging.

A number of my patients struggling with EDs are either vegetarians or vegans, which can result in nutrient deficiencies including calcium, iron, and vitamin B12. Calcium deficiency can lead to osteoporosis, which can be tested for by doing a DEXA bone scan. Iron and vitamin B12 deficiencies can be detected by blood tests. In some cases, supplementation with these nutrients might be suggested to aid in the prevention or management of medical conditions.

At the end of the day, I try to focus on food with my ED patients, as most nutrients are best absorbed from dietary sources. But in some severe cases, supplementation might be indicated if the individual is unable (or unwilling) to eat the foods necessary to attain these nutrients. Refeeding can be a very uncomfortable experience for those struggling with EDs. Most of my patients who are refeeding experience painful bloating, cramps, constipation, and delayed gastric emptying, which can make it feel nearly impossible to eat anything at all. In those situations, supplementation with certain nutrients might be indicated until the individual is able to start eating normally again.

If you are considering supplements for either your own or your child’s ED, please consult with your physician before trying anything on your own. Your physician will be able to assess any nutritional deficiencies through a number of diagnostic tests and then can guide you in the right direction.

He Said, She Said: “Do Your Job”

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He Said

The main reason I enjoy following sports is not entertainment, but rather because I am fascinated by how athletics reflect life’s themes with such clarity that the lessons are blatantly apparent. Earlier this month, the New England Patriots won the Super Bowl behind Bill Belichick’s “Do Your Job” command. In other words, perform your role as you are taught, trust that your teammates will do the same, and as a result, the team as a whole will experience success.

This same lesson applies to health care. In fact, practitioners actually use the word “team” when describing the collection of providers who collaborate to help a given patient. This treatment team consists of a primary care physician and any number of specialists, including psychotherapists, dietitians, physical therapists, and others who are all essential to the patient’s care.

Equally essential is understanding the importance of each practitioner doing his or her own job, no more, no less. Nobody is an expert in every single facet of health care; consequently, all providers have limits to their scopes of practice. One of the traits that separates the best practitioners from their peers is recognizing where their boundaries lie and taking care not to step over them.

Unfortunately, some practitioners, who no doubt have their hearts in the right places, exceed these boundaries. Quite often, Joanne and I encounter situations where other members of a treatment team have provided the patient with nutritional advice. The result is almost always confusion and a step backward in the patient’s care.

For example, one of my patients recently told me about different pieces of nutritional advice that his primary care physician and his personal trainer had given him. In both cases, the guidance he received was off base. My poor patient, he was so confused that the result was a temporary undoing of progress he and I had achieved together.

The doctor no doubt meant well. Doctors are absolutely critical in health care. Primary care physicians are trained to be first-line responders for conditions ranging from splinters to cancer. Specialists dedicate their lives to their individual disciplines, and their unique expertise oftentimes quite literally makes the difference between life and death. Personally, I owe an unpayable debt of gratitude to my neurosurgeons, Dr. Griffith Harsh and Dr. Jean-Valery Coumans, for giving me the quality of life that I have now.

However, doctors receive a scarce amount of nutrition education in medical school. According to one study, students received only 23.9 hours on average of nutrition instruction in medical school, which amounts to basically a long weekend workshop. That is almost 24 hours more of formal nutrition education than most people, but still nowhere near what dietitians receive.

During a Google search, I came upon a blog entry a doctor wrote in which he attempted to dispel the “myth” that doctors do not receive adequate nutrition training. He cited the mountains of organic chemistry, biochemistry, and physiology that medical students take in addition to learning about the roles that various nutrients play in the body. However, his argument only serves to prove my point. The hard science is of course important, but so is having a solid understanding and appreciation for how food is complexly intertwined with other facets of life, such as social, cultural, and financial factors. Dietitians, not doctors, receive this comprehensive training, which perhaps explains why so many patients come in here having been given rigid, unsustainable, and plainly unrealistic “doctor’s orders” regarding how to eat.

As a former personal trainer who still maintains my certifications even though I no longer practice as one, I can attest to the important functions that trainers serve. Great trainers can put together workout programs that increase safety, effectiveness, and enjoyment while simultaneously reducing the intimidation, confusion, and boredom that sometimes accompany exercise.

Having been through the personal training certification process and having worked in the field though, I can tell you that most trainers have no nutrition knowledge beyond what most laymen hold. Looking through the manual that I studied for one of my certifications, I see that the nutrition chapter is 15 pages long. As I have argued before, sometimes a little bit of nutritional knowledge is worse than none at all. Registered Dietitians hold degrees in the field, complete rigorous internships that include everything from chopping squash in a cafeteria kitchen to ordering intravenous feedings for intensive care unit patients, pass credentialing boards, and hold state licenses to practice dietetics. Fifteen pages versus all of that. From whom would you rather receive your nutritional guidance?

Similarly, we dietitians have limits to our expertise as well, and we must respect them. Because emotions can be so intertwined with food, strong feelings and deep-rooted issues sometimes arise during our sessions. Acknowledging these emotions and taking them into account are important parts of our work, but we cannot address them as effectively as trained therapists can. For that reason, providing the quality of care that our patients deserve sometimes means suggesting that they consider adding a therapist to the team.

Practitioners of all disciplines fill important roles in patient care, but if we want to achieve victory, which in this case means helping our patients to the best of our collective ability, then we need to follow Coach Belichick’s guidance by staying within our scopes of practice and trusting that everybody else on the team will do the same.

From the patient’s perspective, keep in mind that well-meaning practitioners sometimes reach beyond the bounds of their expertise in an effort to help, but the further he or she stretches, the less accurate the guidance is likely to be. If you want reliable expertise regarding a particular issue, then seek it from a practitioner who has dedicated his or her professional life to that specialty and let him or her do his or her job.

 

She Said

What an exciting Super Bowl that was! Jonah and I were on the edge of our seats for the entire game, and the finale was just amazing! It got us thinking about the Patriots’ motto this season: Do Your Job. It was clear that every Pats player had such an important role in that game and that each player did his job extremely well. In order to work together as a team, they needed each person to execute his job as he had been trained. And it really paid off!

The Pats slogan got me thinking about how eating disorder (ED) patients need a strong treatment team in place in order to recover. Each member of the treatment team needs to do his or her job to support the patient, and there needs to be a clear line of communication among all team members. In addition, each member needs to try to practice within his or her scope of expertise without taking on the others’ roles.

In ED treatment, the team can consist of a number of different players. If the patient is in an inpatient or residential program, the treatment team will likely include a doctor and/or psychiatrist, a nursing staff, a therapist, a case manager, residence counselors, and a dietitian. In an outpatient setting, the team ideally includes a physician, therapist and/or psychiatrist, and a dietitian who specializes in EDs. It could also include teachers, advisors, deans, coaches, and in some cases, the patient’s family as well. You know the saying that it takes a village to raise a child? Well, it takes a village to help a patient recover from an ED.

As much as we try not to do so, sometimes treatment team members will fumble the ball by giving advice that is outside of our scope of practice. I remember one of my patients had a therapist who was actually making changes to the meal plan I had developed for the patient without talking with me first. Although I am sure the therapist only meant to help, it gave the patient mixed messages about what roles the therapist and I would play. Similarly, there are times when my nutrition counseling sessions seem to take on a more therapeutic nature. Most people have a lot of feelings around food, eating, and weight, and sometimes it is difficult to know where the boundary lies between nutrition therapy and therapy! But I always strive to bring the conversation back to the food and then suggest the patient discuss his or her feelings more in depth with his or her therapist.

Another important aspect of treatment team work is that the team usually functions best when there is one quarterback running the show. In most cases, this individual is usually the ED physician or therapist, although sometimes it can be a case manager or even the dietitian. In reality, the patient is really the quarterback, but when he or she is really struggling with ED, a trained professional is the safest bet to step in and manage treatment.

Above all else, communication is the cornerstone of a successful treatment team. Clear communication, whether by phone, in person, or via email, can really make such a difference in a patient’s quality of care. If we are all on the same page, the patient will get a consistent message and hopefully feel more confident and secure that his or her treatment team is a cohesive unit that will help him or her eventually beat ED.

He Said, She Said: Nutrition in Schools

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He Said

Wellness class. The other freshmen and I thought the class was such a joke that if you told then-15-year-old Jonah that in a couple of decades he would wittingly choose to incorporate the word “wellness” into his business’s name, the cognitive dissonance would have rocked his adolescent world view.

Wellness class was gym without the, well, gym. The teachers were the same, but instead of leading us through units of volleyball, basketball, and badminton, they taught us about health and nutrition. The overarching culture, however, was consistent. Gym was the informal time of day, the high school version of recess. It was a time to let loose, move our bodies to one extent or another, and measure ourselves against our peers, both figuratively and, as you will read, sometimes literally. You had better believe the spirit of competition bled into the wellness classroom, too.

Even at 15, I could tell that the school’s approach to wellness was off base. We used to undergo various exercise performance tests (pull-ups, submaximal cycle ergometer, sit-and-reach) as well as anthropometric exams (weight, height, body composition). All of these evaluations happened in front of the group, so we all knew how each of our peers had fared. Gee, sounds like a great plan; what could possibly go wrong?

After the testing was over and it came time for the teachers to gather us together and offer congratulatory certificates to those of us who had what I suppose were good results in the eyes of the teachers or whatever norms against which they measured us, I crumpled up my award in my hands on the spot. Immediately, I felt guilty as if I had disrespected the teachers who had given it to me, but as time went on, I confirmed that my intuition was right.

If the teachers gave some of us certificates based on our body measurements, what kind of message did they send to all of the other students who did not receive such certificates? As a result, how do you think those students felt about themselves and their bodies? Similarly, how do you think their certificate-holding peers viewed them? The teachers indirectly started the bullying by posting their body mass indices and body composition results, thereby publicly shaming them, and other kids were more than happy to pick up the harassment where the teachers left off.

See, here’s the thing: If a teacher is conveying oversimplified and misguided lessons about how we can manipulate our bodies and our weight based on how we eat and exercise, and then they single out the kids whose bodies happen to be larger, the message they are indirectly teaching is that something is wrong with these larger students, that they are not doing enough to take care of themselves, that they are lazy and/or eat too much. And we wonder how weight stigma forms and gets perpetuated.

I still remember two of the largest kids in my class as well as their body composition results. These data should never have been my business to know. What does it say about the culture the school created that these results have stuck with me all this time? That was not wellness.

If we are going to even consider teaching nutrition in schools, we have to scrap the status quo and reexamine fundamental questions of who will do the teaching, what expertise do they hold, what environment will they create, will they reinforce stigma or break it down, and most importantly, what lessons will students actually absorb about their relationships with food, physical activity, and their bodies. If we cannot provide answers that are worthy of their own certificates of satisfaction, then we should not be teaching nutrition in schools at all.

 

She Said

As the holidays have come to a close, it’s back to reality for most of us. For some of my patients, that means back to school. Lately, it seems like I have been hearing a lot about school-based nutrition programs from my patients. Some of these programs are being run in their health classes, while others are part of their biology curriculum or other classes. It got me thinking about the subject of nutrition and school. Should nutrition be taught in elementary, middle and high schools? If so, who should be teaching it to the students? What should the nutrition course cover?

Given that the vast majority of my patients are those struggling with eating disorders, I have some mixed feelings about nutrition in school. On the one hand, I think it’s important for kids to learn about how to take care of themselves and the consequences of their lifestyle choices on their health. For instance, it makes sense to me for kids to learn about different nutrients and how they can help them grow and thrive.

But I worry that along with this helpful information, the kids might be learning a whole different lesson. From what I’ve heard, many of these nutrition programs are focused on making sure students maintain a healthy weight and actually scare them about the potential dangers of being overweight. As Jonah and I have written about extensively, health and weight are not synonymous; lifestyle behaviors are a much better predictor of health outcomes. This means that even if someone falls into the “overweight” or “obese” categories on the BMI scale, they are not necessarily doomed to poor health. Similarly, someone who falls into the “normal” weight category might not be healthy. It’s the behaviors that make the difference, not weight.

In addition, kids (and adults) come in a wide array of sizes and body types – we are not all meant to be slender. Genetics are a huge determinant of body weight. And as we have noted many times before, diets (or any program or restrictive way of eating meant to alter one’s body size) fail 95% of the time, usually ending up in weight regain. Oftentimes, I hear that school nutrition programs propagate the false idea of “calories in, calories out” in regards to weight. It’s just not that simple.

Unfortunately, the main message that most of my patients glean from these school nutrition programs is “fat = bad” and “these are the foods to avoid in order not to be fat.” In one case, one of my patients told me her biology professor had her students calculate their resting metabolic rates and then keep a food journal to log their calories to later evaluate if they were eating too much to maintain their weight. Another one of my patients told me that she actually learned about eating disorders from an educational video shown in her health class and that’s when her bulimia started. For someone who has the genetic predisposition for developing an eating disorder, these types of messages and activities can actually trigger them to start restricting.

What’s the solution to this problem? One thought I had is that schools could hire a registered dietitian as a nutrition consultant who is well versed in eating disorders and Health at Every Size®. Perhaps that dietitian could run a nutrition program for the students or train teachers to do so. Ideally, I would think the program should be focused on being weight-neutral, helping students embrace a variety of body types and sizes, and not advocating for restricting certain foods. In addition, maybe it would be a good idea to make nutrition programming an optional part of the school curricula, as some parents might not want their child to learn about nutrition in school. Perhaps the nutrition course could be offered as a voluntary program after school hours for those who are interested in it. I’m not sure what the right answers are to these questions, but I hope that as our society becomes more educated about health and weight, things will change in our schools.