Crime and Punishment

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Michael Felger, a sports radio host in Boston, received national attention last week for his extended rant in reaction to the death of Roy Halladay, the former pitcher who was killed when the plane he was piloting crashed into the Gulf of Mexico.

“It just sort of angers me,” Felger said. “You care that little about your life? About the life of your family? Your little joyride is that important to you that you’re going to risk just dying. You’re a multimillionaire with a loving family, and to you, you have to go get that thing where you can dive-bomb from 100 feet to five above the water with your single-engine plane with your hand out the window. ‘Wheee! Wheee! Yeah, man, look at the G-force on this! I’m Maverick! Pew pew pew! Yeah, man, look at this, this is so cool.’ And you die! Splat! If I die helicopter skiing, you have the right to do the exact same thing I’m doing to Roy Halladay. He got what he deserved.’’

Felger took it too far and he knows it. “In a nutshell, I would say that I feel bad about what happened on a lot of levels,” he said the next day in his on-air apology. “I feel bad about what I said and how I conducted myself. To say it was over the top and insensitive is really stating the obvious.”

However, Felger limited his contrition to the poor timing and distasteful nature in which he communicated his points, but he held firm to his core arguments. “I believe what I believe,” he noted, a sentiment to which he returned over the course of the four-hour show to emphasize that he was not apologizing for his feelings, but only for how he conveyed them.

That is unfortunate, for as much credit as I give Felger for taking responsibility for his tone and tactlessness, going out of his way to double down on his stated beliefs suggests a failure to understand the inherent dangers of condemning someone else for making a choice or engaging in an activity that subjectively feels too risky to the person passing judgment.

Stunt flying, as Halladay was reportedly doing at the time of his crash, is inherently dangerous, but all choices exist on a risk continuum that never quite reaches zero. Every single one of us makes decisions on a daily basis that someone else might deem too risky, but we weigh the pros and cons and ultimately take the risks that in balance feel worth it. Some of us cross busy streets, gather in crowds, work stressful jobs, play contact sports, get behind the wheel, mount bicycles, undergo elective medical procedures, attend protests, testify against violent defendants, and yes, some of us stunt fly. We all draw a line somewhere regarding what we, personally, feel is too risky, but who is to say that our placement is any more right or wrong than where someone else draws their own?

For another example of a choice that could be considered too risky, Felger need not look any farther than the chair next to him. His co-host, Tony Massarotti, elected to pursue a weight-loss treatment plan at a local diet center and pitches the program via radio spots every afternoon. Hopefully he knew going into it that he is unlikely to sustain his lower weight and that weight cycling, regardless of one’s baseline weight, is associated with a higher overall death rate and twice the normal risk of dying from heart disease.

Hopefully, nobody will claim, “He got what he deserved,” if Massarotti dies of a heart attack, yet some do just that. A fervent raw vegan that I used to run against once suggested that we should treat omnivores who die of myocardial infarctions as suicide victims because, in his eyes, their deaths were self-induced by years of consuming cooked foods and animal products. They are shooting themselves, he explained metaphorically, they are just pulling the trigger really, really slowly.

To suggest that people who follow a diet other than his own are killing themselves is to pass quite a judgment, one that is particularly curious since other restrictive diets have their own staunch followers who similarly believe that raw vegans are bringing about their own demise. Ours is the path to salvation, extremists believe, while others are deservedly damned for worshiping another dietary God.

Across the street from the radio station, a related story of crime and punishment is apparently unfolding at New Balance, where, according to someone I know who works there, the company has started measuring employee body mass index (BMI) annually and now charges fat workers more for health insurance than their leaner colleagues.

Perhaps New Balance’s intent is to encourage employee engagement in behaviors subjectively considered healthy and/or to financially demand more of the individuals who are seen as the greatest burden on the healthcare system. In either case, the company is erroneously conflating behaviors, health, and anthropometrics. To charge heavier people more for health insurance is to issue a stiff sentence after an unjust conviction.

The policy is a clear case of discrimination that exacerbates weight stigma and risks worsening the health of fat people, in part by encouraging them to pursue weight loss, sometimes by very dangerous means, in order to be treated, both financially and otherwise, like everyone else. Such a policy also negatively impacts thinner people. One of my patients, the child of a New Balance employee, is working to recover from a restrictive eating disorder and exercise bulimia that were triggered by – get this – a fear of becoming fat. Given how heavier people are treated, including by New Balance, who can blame this kid for wanting to avoid such torment?

The accumulation of insurance payouts for this patient to attend regular and ongoing appointments with me and the rest of the treatment team is certainly expensive. With this child representing just one small twig on the tree that survives on the light that is New Balance’s insurance coverage, perhaps this reprehensible policy will increase, not decrease, the totality of the company’s financial healthcare burden. If that possibility comes to fruition, I will borrow a line from Felger and decree:

They got what they deserved.

Holiday Survival Guide

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It’s November, and that means the holiday season is upon us. Many of my patients have mixed feelings about the holidays. On the one hand, these celebrations can be a joyous time with one’s family and friends, full of tradition and connection. On the other hand, these same gatherings can be highly triggering and lead to serious anxiety. Of course, the fact that most holiday celebrations are centered around food can complicate matters even more.

While I love my family and cherish the holiday celebrations we have together, it can still be challenging at times. As I have written about previously, my family does not really understand the principles of Health at Every Size® (HAES) and Size Acceptance. In addition to this, my sister is Oprah Winfrey’s personal Weight Watchers coach and firmly entrenched in diet culture. Needless to say, my family gatherings can be seriously difficult at times!

Over the years, I have accumulated some practical strategies for dealing with challenging family situations, so I thought I would share them with you. Keep in mind that not all of these strategies will work for you, but, hopefully, one or more of them will aid you in navigating these tricky situations and permit you to enjoy the holiday season.

1. Create Safe Spaces

One way that I have found to help my family gatherings be less triggering is to ask my family to refrain from talking about dieting, weight loss/gain, or judgments about weight or food choices during our time together. This can be achieved by sending an email to the main holiday participants ahead of time or making a few phone calls. Another way to achieve this would be to send along some HAES materials to explain the basics. Finally, if you feel uncomfortable reaching out to everyone yourself, you could ask your significant other or trusted family member to relay this information to everyone else.

2. Have an Ally

While this might not always be possible, bringing a supportive friend, partner, spouse, or family member to a holiday gathering can be tremendously helpful. Ideally, this person would be someone who understands/is open to HAES and Size Acceptance and could advocate for you if needed. If your ally cannot be with you at the actual event, making a plan to talk, text, or Skype with them before and after the gathering can also be helpful and make you feel more supported.

3. Take Space

Sometimes despite best efforts, family members or friends will talk about dieting, weight, and/or moralizing food choices. Unfortunately, this is common practice in our society, and many people (especially women) use it as a way to bond with each other. If the conversation turns to these triggering topics, you have every right to get up and leave the table, room, or conversation. Take a walk outside, hang out with your nieces and nephews, play with the family pet, or just find another space and take a few minutes. Sometimes all you need is a few moments alone.

4. Set Boundaries

If a friend or a loved one consistently makes comments about your weight or food choices, you have the right to tell them that this is unacceptable. In the moment, it can feel very difficult to stand up for yourself, so it might be helpful to think of some replies ahead of time. Some examples could include “Please don’t talk about my weight,” “I would prefer it if you didn’t make judgments about my food choices,” or “My food choices are none of your business, so please do not comment on them.”

5. Practice Regular Self-Care

While of course I would recommend engaging in self-care activities year-round, the holidays are an especially important time to do so. Practicing intuitive eating and physical activity, getting enough sleep, and managing stress are some basic ways to take care of yourself. If you are in therapy, it can be helpful to prepare for challenging situations with role-playing, i.e., have your therapist help you practice your responses to difficult family members or friends.

In the end, sometimes holiday gatherings are just about getting through it with as little scarring as possible. Inevitably, Aunt Edna will start talking about her latest cleanse, or cousin Fred will comment on how much weight someone has gained/lost. In some cases, there really is nothing you can say or do to change a family member’s or friend’s thoughts about weight/dieting/food, so the best thing you can do is agree to disagree and move on. Remember that these events are time limited, meaning that they will not last forever. I hope that some of these strategies will be helpful for you during the upcoming months – you can do it. Happy Holidays!

You (Still) Are Not Tom Brady

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

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

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

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

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

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

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

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

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

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

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

Fitness Trackers

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He Said

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

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

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

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

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

 

She Said

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

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

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

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

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

Sugar makes you fat?

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

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

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

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

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

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

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

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

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

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

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

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

Are you doing intuitive eating wrong?

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He Said

First, a word about what intuitive eating is. In our culture, we are often taught that we cannot trust ourselves to guide our food choices. Instead, we use apps to track our calories and macronutrients, food models and sections of our hands to dictate portion sizes, and various books and online resources that tell us which foods to eat and which ones to avoid.

Eating based on external factors is problematic and often unnecessary. These behaviors instill and reinforce issues of guilt and deprivation regarding our food choices, and they also give the impression that some algorithm knows better than our bodies how we should be eating, which is typically nonsense.

Our bodies are actually quite good at guiding our eating behaviors – young children, for example, are generally great at knowing when, what, and how much to eat (that is, until we screw them up by teaching them to override these cues). We just have to get back to listening to and trusting our bodies again, and that is what intuitive eating is about.

The way I sometimes explain it to patients is to recall Maslow’s hierarchy of needs and discuss that in nutrition we have a similar structure. At the base, someone needs food. Period. If food security is an issue – and such scarcity can be brought on by external issues like finances or access, or they can be self-imposed, such as by dieting – then not much else matters. At the very top is medical nutrition therapy, which is how we eat in order to manage issues with our health, such as high blood pressure.

The middle layer is comprised of our relationship with food: How do we decide what, when, and how much to eat? People oftentimes want to jump right to the top, which is understandable. After all, if someone is concerned about a medical condition, of course they want to dive right in and talk about how they can help the issue through food. The problem, though, is that if we ignore the middle layer, then we do not have a proper context for incorporating the medical nutrition therapy, which can consequently come across as a diet.

Situations do exist in which jumping right to the top is the best course of action. If someone comes in with Celiac disease, for example, discussing matters like safe and unsafe foods, hidden ingredients, and cross-contamination will be high on our to-do list. The difference between this kind of scenario and most others is that with Celiac disease, the issue is more black and white: unsafe foods for this person really do exist and the patient must completely abstain from them. The same could be said for someone who comes in with a life-threatening food allergy.

In contrast, most nutrition-related conditions, including high cholesterol, high blood pressure, and blood sugar concerns, exist in a gray area. We have guidelines, but not rules, so the patient is going to have to make food decisions every single time they eat. Do they really want to be relying on some app, meal plan, or an oversimplified list of “good” and “bad” foods to tell them what to eat for the rest of their lives, or do they want to develop a healthier relationship with food that will enable them to incorporate the medical nutrition therapy in a way that still honors their hunger/fullness cues and cravings? That is why we focus on intuitive eating as a precursor to medical nutrition therapy.

With all that said, the most common way I find that people misuse intuitive eating is the belief that if they eat when they are hungry, stop when they are full, and eat the foods that their bodies seem to be asking for, they will automatically lose weight. This belief is understandable; after all, the idea of energy balance (calories in versus calories out) is so pervasive in our society that people just assume that if they reduce how much they eat, then of course they will lose weight.

In reality, while energy balance is certainly true from a thermodynamic point of view, our bodies are complex open systems, and the math is not as straightforward as our apps would have us believe. If someone consumes a 100-calorie slice of bread, the number of calories he actually absorbs from it will depend on factors such as his genetics and his gut microbiome, whereas someone else could eat that same slice of bread and absorb a different amount of calories. Furthermore, calories consumed affect our calories expended (Think of someone whose metabolism slows as a result of restriction.), so the two sides of energy balance are not as independent as many believe.

Despite my warnings, some patients still believe that if they just learn to eat intuitively, they will lose weight. Thus, they treat intuitive eating as a diet, which is a setup for failure. Time and time again, I have seen such people develop some basic intuitive eating skills early on, but their progress stalls as soon as their weight loss does. Someone might be able to keep one foot in the weight loss and intuitive eating worlds for a short while, but quickly this straddling leads to stumbling.

In order to extensively rediscover our intuitive eating skills, we absolutely must ditch any expectations regarding physical changes, such as weight or body composition, that our bodies will make as a consequence of our pursuits. In other words, if you are using intuitive eating to lose weight, then really you are just dieting, and the results are probably going to be as dismal as they would be with any other weight loss pursuit.

 

She Said

As many of you know, a lot of the work that Jonah and I do with our clients is around helping them become intuitive eaters. While on the surface the concept of intuitive eating seems quite simple – eat what you are hungry for in the amount that feels comfortable and satiating to your body – there are a number of complicating factors that can get in the way of an individual being able to do this. In some cases, even though an individual might truly want to be an intuitive eater, they might not really be able to do so. The clearest example of this is when I am working with patients struggling with eating disorders (ED).

When an individual engages in eating disorder behaviors, such as restriction, bingeing, purging, or overexercise, oftentimes this will take a toll on their digestive system and their ability to distinguish hunger and fullness cues. As such, I have heard from many patients that they either never feel hungry or never feel full (or in some cases, they cannot even describe what hunger/fullness feels like to them). Since being an intuitive eater depends on the individual being able to not only recognize their hunger and fullness cues but also be able to attend to these cues appropriately, those individuals with ED can find it to be nearly impossible to eat intuitively.

Patients who come to see me and are early on in their recovery process will often bring in with them a meal plan they have been following. In general, I am not usually a fan of meal plans, as I discuss here, but in some cases, they are necessary to help individuals with EDs reestablish their hunger and fullness cues. Making sure that the body is receiving 3 meals and a few snacks throughout the day helps to undo some of the damage that the ED has done to these cues. The body comes to expect that it will be fed at regular intervals; therefore, you will feel hungry at certain times. Feeling hungry periodically is a normal body process, a survival mechanism that tells you when your energy stores are low and your body needs fuel. When a patient with an ED goes long periods of time without eating or not eating enough, the body actually habituates to its hunger signals, and eventually the individual cannot even recognize or feel hunger. Meal plans are an essential step (for some) to get their body back into a natural rhythm of fueling their body when they are hungry.

Sometimes when I have been working for a short while with a patient struggling with ED, they will express the desire to try eating intuitively. While helping my patients become intuitive eaters is the ultimate goal in my work, it is not something I often dive into headfirst with my ED patients. On a number of occasions, I have had individuals try to eat intuitively too soon in their recovery process, and they will find themselves either not eating enough (as they still do not have accurate hunger cues) or eating more than their body is asking for due to a fear of getting hungry.

I like to encourage these patients to try out an approach that is halfway between meal plan and intuitive eating. To achieve this, I will use a “modified” intuitive eating meal plan as a stepping stone to intuitive eating. The plan typically involves having the patient eat every 3-4 hours (during waking hours, of course!) and making sure that they have carbohydrate, protein, fat, and either a fruit or vegetable at each meal. Instead of specifying that the patient needs to have X number of carbohydrate exchanges, I give more of a range (e.g., “have 2-4 carbohydrate exchanges at breakfast”) as this gives the patient some flexibility to eat more if they are hungry for it or eat a bit less if they are not. In a way, it is giving the patient some intrinsic choice around their food while still giving them the structure that their body needs. Once the patient has mastered this “in-between” meal plan for a substantial period of time, we would discuss trying to work on eating more intuitively.

In the end, the goal is to help my patients learn to trust their body’s innate wisdom – that it will tell them when they are hungry, what they are hungry for, and how much is enough to satisfy them. As long as the individual does not jump into intuitive eating too quickly (i.e., before they are ready), they will be well on their way to developing a healthier relationship with food and their body.

“Too Fat” vs. “Too Thin”

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Those of us who have had an eating disorder know firsthand that while recovery is possible, the road can sure be difficult. The eating disorder voice is powerful and can make people do and say things they otherwise would not express if their bodies and minds were in healthier places. A woman who is struggling mightily to recover from anorexia nervosa posted on a message board criticism of her treatment team for saying that being “too thin” is problematic while being “too fat” is okay. Does she have a point?

The treatments for someone who is “too thin” versus “too fat” are actually more similar than some people realize. In both cases, the etiology of the person’s size matters as well as whether or not the origin is pathological.

For example, consider two people, each of whom is “too fat.” One person has a healthy relationship with food and physical activity, no significant medical or psychological issues, has always been “too fat,” and comes from a family of people who are of similar builds. Meanwhile, the other person is “too fat” due to binge eating disorder. The former receives no treatment while the latter receives treatment for his eating disorder, not his body size.

Now consider another example of two people who are both “too thin.” One person has a healthy relationship with food and physical activity, no significant medical or psychological issues, has always been “too thin,” and comes from a family of people who are of similar builds. Meanwhile, the other person is “too thin” due to anorexia nervosa. The former receives no treatment while the latter receives treatment for his eating disorder, not his body size.

[Note: Anyone of any size can have an eating disorder, including some “too thin” people who experience binge eating and some “too fat” people who restrict. In reality, we never completely know what struggles someone might have just by looking at them.]

In both cases, whether one is “too fat” or “too thin,” any treatment is targeted at the underlying pathology, if one is present, not at the body size itself. However, for the person who is “too fat” due to binge eating disorder, we let the person’s weight take care of itself as they progress through treatment, as opposed to focusing on the weight. He may or may not lose weight as his disorder subsides, but altering his body weight is not the goal for two reasons:

(1) While being “too fat” is associated with an increased risk of medical woes, causal relationships have not been established, contrary to popular belief. In chapter six of Health at Every Size, Dr. Linda Bacon does an excellent job of explaining the correlations between body weight and the conditions for which weight is often blamed.

(2) While our bodies are relatively adept at gaining weight, they are resistant to long-term weight loss. In other words, interventions aimed at lowering body weight are most likely to result in ultimate weight gain, so in that sense even if the patient’s weight itself is the problem, he is only likely to exacerbate the condition by trying to lose weight.

In contrast, for the person who is “too thin” due to anorexia nervosa, weight restoration is an important part of his recovery. When someone becomes unnaturally thin due to restriction, overexercise, or other disordered behaviors, the body sheds not just fat mass, but also bone structure and tissue from organs, including the brain.

Dr. Ovidio Bermudez, Medical Director and Chief Medical Officer at the Eating Recovery Center, a behavioral hospital for children and adolescents, gave a talk at the 2014 Hynes Recovery Services conference in which he explained, “As a young girl starves herself, or a young man starves himself, and they knock off their sex steroid production, one of the important aspects of that, one of the downstream consequences of that, is that they may also be unintentionally impacting very important aspects of brain development, including neuronal growth.”

When discussing recovery, Dr. Bermudez noted that brain atrophy can be documented just as we can document bone demineralization, and then he continued, “If you stay underweight, your brain size does not recover. So you have to really normalize your weight in order for your brain size to recover.”

Dr. Kim Dennis, former Medical Director at Timberline Knolls Residential Treatment Center and current Medical Director at SunCloud Health, presented at the same conference and explained further, “When a patient with anorexia also says they’re depressed or a parent says they’re depressed, many times that’s not depression. That’s simply what looks like a mood disorder, but it’s based on the fact that their frontal lobes are shrunk, they can’t display affect, they have lower levels of neurotransmitters in their brain, and the cure to that, the treatment to that, is not necessarily Prozac, but it’s food and refeeding.

“Many times patients with anorexia really, really value their brains, and a lot of times you’ll tell someone with anorexia, ‘You’re not thinking straight because you’ve lost neurons. Your brain looks more like a 60-year-old with early dementia than an 18-year-old.’ And they’ll say, ‘I know a lot of anorexia patients might look that way but my brain doesn’t.'”

She then referred to a slide showing a brain with reduced volume due to restriction side by side with a healthy brain. “It’s important for us [clinicians] to realize when we’re working with a malnourished, underweight patient that there’s no amount of CBT (cognitive behavioral therapy) or DBT (dialectical behavioral therapy) or trauma work that’s really going to be effective unless that person’s brain is regrown first. So, first and foremost, food is medicine.”

Left: Normal control. Right: Patient with anorexia nervosa. (Image courtesy of Dr. Kim Dennis and SunCloud Health.)

Sometimes patients ask me to differentiate how my role, as a dietitian, differs from the roles played by other practitioners on their treatment team, namely their therapist. Oftentimes, I explain that eating disorders are mental illnesses that get played out through food. My role is to provide nutritional support during the early stages of recovery and then to help someone form a new and healthier relationship with food as the eating disorder recedes, but the bulk of the recovery happens in the therapist’s office.

For the reasons that Dr. Bermudez and Dr. Dennis explained, the brain cannot rebuild without weight restoration, and without an appropriately functioning brain, therapy – and therefore eating disorder recovery – becomes that much more of an uphill battle.

Privilege

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We welcome questions, feedback, and constructive criticism from our patients and readers, even if their opinions differ from ours, so long as the comments we receive are respectful. In response to a blog I wrote a few months ago discussing the intersection of nutrition and politics, one reader sent me the following message.

“I believe people’s passions for their careers should be evident. When someone comes through your door, they are seeking you out for your nutrition knowledge. You are brilliant at your job. The appointment is a give and take of information. However, I believe that people’s passions for politics should be kept private unless all parties have mutually agreed to share their views. Our views are slanted by all we know. As a former educator, we used to feel it was our job and it was our responsibility to try to remove our personal view from the workplace.”

Let me go through her points and respond to them one at a time.

“I believe people’s passions for their careers should be evident. When someone comes through your door, they are seeking you out for your nutrition knowledge.”

People seek out dietitians for all sorts of reasons. One person may have high cholesterol and hopes of lowering it via medical nutrition therapy, while someone else might have a history of chronic dieting and envisions building a healthier and more peaceful relationship with food. Some patients stop there, limiting their search for a dietitian to such criteria as perceived knowledge regarding a specific concern, as well as logistical factors, such as geographic location, ease of transportation to and from the office, insurance coverage, and appointment availability.

However, other patients have concerns that extend far beyond such basics. They want to know the person with whom they will potentially be working with and therefore desire some self disclosure on the dietitian’s part. Beyond that, many people value and are seeking a safe space for themselves. They want to know if their prospective dietitian will judge them for their size or behaviors, for example, or if the dietitian holds views on gender identity, ethnicity, religion, sexual orientation, skin color, nation of origin, or physical ability that hinder their ability to provide quality patient care. Sure, nutrition knowledge matters, our reader got that right, but she neglected to consider other factors of importance in a counseling relationship.

“You are brilliant at your job. The appointment is a give and take of information. However, I believe that people’s passions for politics should be kept private unless all parties have mutually agreed to share their views.”

The aforementioned individuals who are searching for a safe space for nutrition counseling need to know that we offer one. Furthermore, people sometimes ask us where we stand on societal issues and what actions are we taking to be a positive force in the world. They want to know what we are doing to combat weight stigma, for example, or to defend their health insurance coverage. Last fall, when we announced that we were donating 100% of the co-pays we collected between Thanksgiving and New Year’s to the Southern Poverty Law Center – an organization that fights hate and teaches tolerance – one ex-patient messaged me out of the blue to voice his displeasure while the rest of the feedback we received was positive.

Our practice’s philosophy is reflected in how we do our work – for example, we believe in collaboration and equality with our patients, which is why I like the symbolism of the round table in my office – and said philosophy also includes that we offer individualized nutrition counseling because we know that what works best for one person might not work so well for someone else. With that in mind, time spent in appointments belongs to my patients and I do not force political discussions on anyone, nor do I initiate them. If someone wants to focus on which fruits are highest in soluble fiber or some other superficial topic of hard science, no problem, fine by me, but my very next patient might be questioning what the point of working on their nutrition even is when they fear being murdered in a hate crime, having their health insurance stripped away, losing a loved one to deportation, etc. so I have to be malleable enough to respond to whatever feels most pressing to the person sitting with me at a given point in time.

“Our views are slanted by all we know.”

Exactly. With that in mind, I respectfully suggest that our reader reconsider the rest of her argument. Politics may have no place in nutrition counseling based on her world view and life experiences, but other people feel quite differently based on their own roads traveled.

“As a former educator, we used to feel it was our job and it was our responsibility to try to remove our personal view from the workplace.”

Just because I was a student does not mean I am an expert in education, but in my layman’s view I can envision issues with educators inserting their own political beliefs into their work. However, I question the parallel between that and nutrition counseling.

Teachers grade their students, sometimes write them recommendations, and are typically called by honorifics such as mister. Given a teacher’s position of power over their students, I can imagine that issues might arise if they reveal their own political leanings. Some of our patients, particularly children and adolescents, may expect a similar power dynamic when they first come to our practice, but we quickly dismantle that and emphasize that we are all on the same plane. We preach equality and collaboration, and nobody ever calls me Mr. Soolman twice.

Public education systems are taxpayer-funded institutions and my layman’s understanding is that they are supposed to accommodate the masses. If a teacher’s political discussion negatively affects the experience of a child who has every right to be there, I can imagine how that would be a problem, especially if said child does not want to or has no means to seek an education anywhere else. As a similar example, consider emergency room doctors who refused to issue the morning-after pill because doing so conflicted with their own beliefs. There was no room for such convictions in a hospital that is supposed to serve everyone, especially when time was of the essence and finding another clinic in short order might have been impractical or impossible.

Soolman Nutrition and Wellness, however, is a private practice, not a public institution, and patients have the choice whether to work with us or not. Sticking with the education theme, perhaps the best comparison would be that of a private school. If a Catholic high school wants to make daily prayer a way of life and take students on a field trip to Washington DC to participate in a pro-life march, so be it; those students and their families knew what they were getting themselves into when they choose to enroll there. If a family desires a more secular education, they can pursue enrollment at another private school or utilize the public school system to which they are entitled.

The reality is that while some people get irked by the occasional mention of politics in our blogs or e-newsletters, others feel comforted by those same inclusions. To feign political neutrality or to sidestep the topic entirely is still in itself to proclaim a stance and we would have to face the ramifications of our silence. We appreciate everybody who comes to our practice, but we cannot be everything to everyone; if we must turn off the privileged in order to welcome the vulnerable, we would rather do that than the opposite.

Real Reality

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Some of you may or may not know, but I am a reality TV fan. I know, I know, it definitely isn’t doing anything for my IQ points, but watching these shows is one of my favorite ways to unwind and relax. The ridiculous scenarios and personalities are entertaining and help me suspend my own reality for 52 minutes. Now, while I am not a fan of all reality TV, I have been known to watch some of the “Real Housewives” shows on Bravo, and lately, I have been watching episodes of the “Real Housewives of New York City” and the “Real Housewives of Orange County” (RHOC).

This season of RHOC, one of the storylines is about how Shannon, one of the housewives, has gained weight since the last season of the show. Shannon cries to the camera about how ashamed she is of her body, how “disgusted” she is with herself, and how she cannot believe that she has let herself go. Shannon attributes her weight gain to eating to cope with numerous stressors in her life. In addition to this, the camera shows her family (her husband and daughters) making fun of her weight and urging her to eat less.  Some of the other housewife cast-mates also make snarky comments about Shannon’s weight gain to the camera, saying how she should only be eating steamed fish and vegetables.

On last night’s episode, Shannon goes to see her chiropractor/health guru to help her get her body back to where it was previously. From the get-go, this charlatan, er, um, health guru, is brutal to Shannon about her weight. Without missing a beat, he asks her to step on the scale and berates her when the numbers show that not only has she has gained a significant amount of weight, her body fat percentage is “dangerously high.” He warns her that these numbers are dreadful and that she has nothing to look forward to other than cardiovascular disease, diabetes, and an early death. If this wasn’t bad enough, he then insists that he take photos of Shannon in just a sports bra and capris from all angles to show her how much weight she has gained. With every turn, you can hear this guy mutter “ugh” when Shannon turns for each pose, clearly vocalizing his disgust. And, of course, Shannon ends up in tears, not because she is upset with the chiropractor, but because she is angry with herself for her weight gain.

I found myself literally screaming at the television screen during this above scene – I was horrified and sickened by it. If this is not one of the most blatant examples of fat shaming that I have ever seen, I don’t know what is. This “health guru” told Shannon that she is less than human for having gained weight, that if she doesn’t “shape up,” she will end up dead before the end of the week, leaving her in tears. And then he made sure she knew how “gross” and “unappealing” she looked while taking her “before photos.”

I think the thing that most upset me about this scene was how it portrays an actual reality for many people living in larger bodies and how they are treated by “health professionals.” I can’t tell you how many of my patients who are “overweight” or “obese” have been subjected to ridicule and abuse from their providers. Several of my patients have been denied fertility treatment until they lose weight, while others have been told that even though their labs and vitals are perfectly normal, their weight will “catch up” with them and lead them to inevitably develop diabetes or heart disease. Even though there is a mountain of evidence that supports Health at Every Size®, that behaviors are more important in determining health outcomes than the number on the scale, doctors, nurses, chiropractors and the like still believe in the weight-centered paradigm and beat their patients over the head with it. Not surprisingly, these fat shaming instances make people of size reluctant to get medical treatment, and in turn can result in even worse health outcomes. Fat shaming is never okay and when perpetrated by health professionals, it’s honestly a form of malpractice.

In any case, after watching the scene with Shannon and her “health guru,” I had had enough. I am no longer a RHOC watcher and I hope that eventually the show will catch on that this storyline is doing so much more damage than good. It is teaching millions of women that they should be ashamed of their bodies if they gain weight, that weight and health are synonymous, and plays into the “obesity epidemic” rhetoric we have been subjected to for the past two decades. Not only that, it could inspire eating disorders in many of its viewers as they will learn that the number on the scale is the most important thing and eating only steamed fish and vegetables is acceptable behavior. Please, Bravo, get your heads out of your asses. This reality show is too real in the worst possible way.

Carbs

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

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

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

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

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

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

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

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