“Sometimes I want to binge so bad.”

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A guy two months removed from spinal fusion surgery has no business moving a 45-pound plate. For that reason, in the late spring of 2014, I introduced myself to a new personal trainer at my gym and asked him to please put away the plate that another member had left on a machine so that I could use the equipment.

Typically, I shy away from new trainers, who tend to pitch themselves to virtually every member they meet in an effort to build their client rosters. As a former trainer myself, I get it, but I also do not like being pressured. This trainer was different though, and once I saw that he was not going to push me for a sale, I began talking with him on a regular basis. That hey-can-you-please-put-this-weight-away interaction turned out to mark the beginning of what has evolved into a friendship of sorts.

In the five years since, we have chatted about superficial matters, such as the rise and fall of the Celtics, as well as issues of more substance, like marriage and fatherhood. Despite the connection we have developed and my opinion that he is generally an excellent trainer, I have never referred my patients to him because of one factor that makes it ethically impossible for me to do so: He unintentionally encourages disordered eating.

Food and eating behaviors are common topics of conversation during his training sessions. Calories, cheat days, tracking apps, Halo Top, junk food, clean eating, intermittent fasting, and willpower are just some of the buzz words and trendy features of diet culture that I frequently hear him and his clients discuss.

My patients and I sometimes talk about these topics too, but the substance of our conversations is entirely different. Whereas I work towards dismantling diet culture and helping my patients understand the harm that comes from relating to food in such a way, this trainer sees these as positives. He tracks his calories, fasts, and weighs himself regularly, and he cites his own weight loss from the past year as evidence that his behaviors are the secrets to success that his clients should replicate.

Last week, one of his clients texted him to say he was going to be a half hour late. With an unexpected chunk of free time on his hands, the trainer came over and struck up a conversation with me while I was stretching. “Do you help people lose weight?” he asked. No, I do not, and I gave him my elevator speech explanation as to why.

His response somewhat surprised me. He told me how difficult weight loss was for him, how exhausting it is to track everything he eats, and how he just cannot keep up the behaviors. “Sometimes I want to binge so bad,” he conceded. The restriction is unmaintainable, he regains the 15 pounds he lost, then resolves to become lean again, reengages in his previous diet behaviors, again loses 15 pounds, and the cycle repeats.

In the last five years, I have overheard literally hundreds of conversations he has had with his clients regarding nutrition, many of which have referenced his own eating behaviors, but never have I witnessed him disclose his struggles and concerns as he did last week when none of his clients were around to hear about them.

So, I told him about the Ancel Keys starvation study and how binge behaviors were commonplace among the subjects once the dietary restrictions placed upon them were lifted. In their excellent book, Beyond a Shadow of a Diet, Judith Matz and Ellen Frankel explain the following:

“What these men [the study’s subjects] experienced as a result of their semi-starvation is typical of feelings and behaviors exhibited by dieters. When the men entered the refeeding portion of the study, the food restrictions were lifted. Free to eat what they wanted, the men engaged in binge eating for weeks yet continued to feel ravenous. They overate frequently, sometimes to the point of becoming ill, yet they continued to feel intense hunger. The men quickly regained the lost weight as fat. Most of the subjects lost the muscle tone they enjoyed before the experiment began, and some of the men added more pounds than their pre-diet weight. Only after weight was restored did the men’s energy and emotional stability return.”

Modern day dieting, I pointed out to the trainer, is really just self-imposed starvation, and it is completely understandable that dieters respond just like the study’s subjects. It is not a matter of willpower, but rather one of biological mechanisms, honed through evolution, that resist weight loss and encourage weight gain in order to help our species survive famines and other times of food scarcity.

Soon enough, our day’s conversation came to a close. He had to get ready to train his client, and it was time for me to head home and prepare for my own day’s work. Just before we went our separate ways, he told me that his clients have no idea how hard it is for him to try to maintain his eating behaviors, and we agreed that we never really know what someone else is dealing with behind the scenes.

Our parting sentiment is also the key takeaway from this blog. Said differently, consider the words of one of our most experienced and knowledgeable colleagues, Dr. Deb Burgard, who once said, “In almost 40 years of treating eating issues, I have found that when someone sits down across from me, I have no idea what they are going to tell me they are doing with food.”

In this trainer’s case, while many of his clients see him as a role model and look to him for nutrition advice, they do not realize that he is struggling and that the behaviors they seek to emulate are actually signs of disordered eating.

The Kids Are Alright

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Weight Watchers, I won’t call you by your new convenient moniker “WW” designed to try to fool the public that you aren’t all about the weight. You might try to kid yourself into thinking that you are just about “wellness” and that the goal of weight loss is just a byproduct of a “healthy lifestyle change.” Nope. It’s just the same crap in a slightly different package. Any way you slice it, the only thing you care about is your bottom line, not helping your customers get healthy. If you really understood health, you would realize that a lifetime of weight cycling, weight stigma, and self-loathing are far more damaging than just staying fat. 

Weight Watchers continues to spread the lie that intentional weight loss is attainable if you just try hard enough. And if you fail at maintaining your weight loss, you, not the diet, are to blame. Bull. If your program worked, you’d be out of business. Even your former financial director Richard Samber stated as much in an interview, explaining that repeat customers are “where your business comes from.”

Where is the evidence that Weight Watchers “works” anyways? The company is famously close-lipped around their long-term success rates. In fact, they cannot demonstrate that anyone, save for a measly tiny percentage of dieters, can keep off the weight they lose for more than five years. And those who do manage to keep the weight off often use disordered eating and exercise behaviors to do so.

Intentional weight loss endeavors, whether they are through Weight Watchers or any other diet or “lifestyle change,” fail 90-95% of the time. Yet our medical community continues to push weight loss on fat patients, telling them that they are at risk of death if they don’t lose the weight. For myself and many other fat people, going to the doctor can be an anxiety-inducing experience, as we are often met with weight stigma and advice to stop eating so much (even if that’s not what’s going on). Many fat people I know just avoid going to the doctor altogether to avoid this weight shaming. Is that health-promoting behavior? I don’t think so.

The notion that weight loss is achievable and maintainable is one of those common beliefs that is put forth by diet culture. Diet culture tells us that being fat is inherently unhealthy and unappealing, that those of us who cannot lose weight are lazy, inept, unintelligent individuals who just aren’t trying hard enough. Diet culture glosses over all of the research that shows how and why our bodies fight like hell against losing weight. Diet culture ignores the facts that repeated dieting and yo-yoing is actually much more physically harmful than just maintaining a higher weight and that shaming fat individuals is not helping anyone but is taking a toll on all of our health and well-being.

Weight Watchers’ latest endeavor, launching an app that targets children aged 8-17, makes my blood boil. In the iconic words of John McEnroe, you cannot be serious, Weight Watchers. Never mind all of the eating disorders that this app will help to create and/or encourage; this app contributes to the weight stigma that plagues our society. It reinforces the idea that being fat is a bad thing and that it must be avoided at all costs. It fosters a feeling of shame in heavier kids, a feeling of being “less than.” 

As a chubby (not fat) child, I was repeatedly told by my pediatrician and my family that my body was wrong. These messages and the messages I got from diet culture led me to develop disordered beliefs around food, exercise, and my body. It wasn’t until I found Health at Every Size that I finally figured out that my body is not to blame. My body doesn’t need to change. Our weight-shaming culture needs to change. And I am honestly scared for the legions of kids and teenagers who are exposed to this toxic culture.

Weight Watchers’ app will teach kids that they cannot trust their own bodies, that their own bodies are damaged or ill-equipped to tell them what and how much they need to eat. This app will create lifelong struggles for these kids, who likely will have a disordered relationship with food and their bodies for the rest of their lives. I cannot even wrap my mind around the amount of psychological and physical damage this program will cause. 

I don’t know if it’s the fact that I have a daughter myself now that this is striking such a chord with me. I fear for her. I don’t ever want her to feel like she needs to make herself smaller to be loved, accepted, or healthy. I don’t want her to spend her life trying to change her body and fear its appetites. I want her to be confident in her body, to trust that it will tell her what it needs, and that her weight is not the measure of her worth. 

So, Weight Watchers, I hope this program fails and you disappear into the ether sooner than later. 

Macy’s

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This month, Macy’s found themselves in hot water for selling plates, made by Pourtions, that many people criticized for encouraging eating disorders and fat shaming.

One of the plates, for example, features three concentric circles, the smallest of which is labeled “skinny jeans,” while the middle one reads “favorite jeans,” and on the largest of the three circles is emblazoned “mom jeans,” insinuating that the bigger the portion, the larger the pants size.

According to Huffington Post, Mary Cassidy, Pourtions’ president, explained, “Pourtions is intended to support healthy eating and drinking. Everyone who has appreciated Pourtions knows that it can be tough sometimes to be as mindful and moderate in our eating and drinking as we’d like, but that a gentle reminder can make a big difference. That was all we ever meant to encourage.”

Her company’s intentions do matter, for if they had purposely intended harm, then this would be a very different matter, but the impact remains the same whether their actions were malicious or an attempt at humor that missed the mark.

“These expectations can actually kill someone, and I know someone it has,” read a tweet from one responder, who elaborated that the plates spread a “toxic message, promoting even greater women beauty standards and dangerous health habits.”

Eating disorders are serious business. They can wreak havoc on one’s health, family, career, and life in general. And yes, they can be fatal. Additionally, they are more common than many people realize.

“As we all know, pressure to be thin leads to dieting, which can lead to a variety of problems, including eating disorders,” I wrote in the April 2016 issue of Boston Baseball. “These life-threatening illnesses are so common in Massachusetts that if the crowd at a sold-out Fenway Park represented a random sample of the state’s population, those in attendance with a diagnosed eating disorder would fill section 41,” which is a large section in the bleachers behind the Red Sox bullpen.

One does not even have to have a diagnosed eating disorder to be suffering the effects of diet culture and weight stigma. We see plenty of disordered eating which can be comprised of a constellation of symptoms, such as a strong good/bad food dichotomy or feelings of guilt and virtue associated with eating behaviors, that does not meet the diagnostic criteria for a specific eating disorder but can be just as disruptive and dangerous.

When we work with people recovering from eating disorders and disordered eating, we help them to uncouple judgment from their eating behaviors, and part of this work entails exploring where they learned such judgment in the first place.

The judgments implied by the Pourtions plates are so blatant that they are self-explanatory, but sometimes the message is more subtle. For example, Trader Joe’s has a line of “reduced guilt” products, such as their low-fat mac and cheese, which implies increased guilt for its full-fat counterpart. One might argue that the “reduced guilt” tag is a tongue-in-cheek marketing gimmick and is not to be taken to heart. Perhaps, but messages like these – whether in your face or toned down – are so commonplace that they are insidious.

Honoring internal eating cues is difficult to do in a society with pervasive messages that our bodies are not to be trusted. We have 100-calorie snack packs, for example, that people often utilize in an attempt to limit their consumption via an external control – in this case, the pre-portioned quantity – but the implication is that 100 calories is the correct amount to consume, that it should be enough food. In some cases, it will be, but 100 calories is an arbitrary amount of energy, and chances are low that it will just so happen to match up with someone’s hunger/fullness cues. If someone gets to the bottom of the bag and yet they are still hungry, the dissonance between their body saying, “Hey, I need more food,” and society saying, “Hey, you have already eaten enough,” is confusing and stressful.

The small print on food labels reads, “Percent Daily Values are based on a 2,000 calorie diet. Your daily values may be higher or lower depending on your calorie needs,” but time and time again, I have patients who believe they should be consuming 2,000 daily calories because food labels imply that this is the standard amount for an adult human. They then have difficulty making sense of their bodies asking for more food than that and feel tempted to restrict in an effort to match the label.

While I am not advocating for the abolition of food labels or snack packs, we have to consider the gap between impact and intent and realize that these tools might not actually be as helpful in reality as they seemed in their creators’ imaginations.

To Macy’s credit, they took the feedback they received to heart; seemingly realized that despite the humorous intent of the Pourtions products, the reality is that the plates are offensive and send harmful and dangerous messages; and consequently stopped selling them.

The Natural Purple Pill?

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At this year’s Cardiometabolic Health Congress, a cardiologist I will call “Dr. Q” began his nutrition presentation with a factoid: 90% of cardiologists reported zero or minimal nutrition education, yet 95% of them felt it was their personal responsibility to discuss it. Meanwhile, 61% of the public thinks that doctors are “very credible” sources of nutrition information.

In other words, we have doctors who do not know what they are talking about talking about it anyway, and patients are listening and trusting them because they are doctors.

He called blueberries “the natural purple pill” and cited research showing that 93,600 women who were studied over 18 years and who consumed three servings of blueberries per week throughout the study had a 34% reduced risk of a myocardial infarction. He then flashed a slide listing the dozens of known chemical compounds in blueberries, asked how we know which nutrient or combination of nutrients is responsible for the benefits, and answered his own question with, “I don’t think any of that really matters,” intimating that the bottom line is that blueberries offer health benefits.

But the underlying mechanism absolutely does matter. He assumed a causal relationship between at least one of the chemical compounds and reduced risk of heart attack, but the relationship between blueberry intake and heart attack risk could also be correlation. For example, the real factor at play might not be some minute compound, but rather money.

Relative to other fruits, blueberries are incredibly expensive. According to data I obtained from Peapod.com, blueberries cost $0.44-$0.64/oz. (depending on the size of the container purchased), which exceeds apples, grapes, melons, strawberries, and all other fruits I examined except for pomegranate seeds ($0.63/oz.) and raspberries ($0.56/oz.)

Could it be that the women in the study who could afford to eat blueberries three times a week also had other financial advantages that enabled them to take better care of themselves, such as the ability to absorb higher insurance costs for office visits and testing, health club memberships, time off from work or no work at all, massages, and psychotherapy?

On the flip side, you know who is probably not splurging on blueberries or able to engage so extensively in taking care of their health? Those working multiple jobs just to get by, those living paycheck to paycheck, those suffering from food scarcity, those relying upon the Thrifty Food Plan, and those who need to make $3.33 stretch enough to buy multiple items to feed their entire family instead of blowing it on a small container of “purple pills.”

“Whether measured by income, formal education, or job status, there is a socioeconomic gradient to health,” Bacon and Aphramor write in Body Respect. “And the greater the inequality in society, the steeper the gradient. The United States has the greatest inequality of all wealthy nations – and the greatest health disparities.”

This is what I was getting at last year when I wrote about nutrition and politics. We talk about the concept of intersectionality and how various layers of oppression aggregate. The further one’s identity lies from that of the pinnacle of privilege – a thin, white, heterosexual, educated, wealthy, American-born, Christian male – the more the individual is subject to oppression.

It might not just be that one’s economic situation makes regularly consuming blueberries unrealistic and limits their access to health care, but that in addition to fretting about cash flow, that person might also have to worry about suffering a hate crime or having their rights stripped away. Even if someone does not fall victim to such misfortune, remember that stress itself is associated with cardiovascular disease, so the very threat itself is problematic.

Assuming that the reduced risk of heart attack was due to a few weekly handfuls of berries without considering the greater context is ridiculous and exemplifies the problems inherent in viewing nutrition solely as a hard science. Anybody who has extensively studied the field should know to consider social, cultural, and other factors, which makes me wonder: When Dr. Q told us that 90% of cardiologists reported zero or minimal nutrition education and yet 95% of them felt it was their personal responsibility to discuss it, was he describing himself?

He Said, She Said: MEDA Conference Takeaways

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He Said

Today’s society is talking more and more about the idea of privilege. We often hear about white privilege, male privilege, and straight privilege, but people less commonly discuss another form that directly impacts our nutrition work: thin privilege.

My thin privilege became obvious to me four years ago when I went to the doctor about back problems. In early 2016, I wrote a blog reflecting on how different my healthcare experience was than that of many of my larger patients who go to their doctors about similar woes. Not only did I receive evidence-based medicine instead of a directive to lose weight, but some of my doctors even made assumptions (incorrect assumptions, at that) about my diet based on my size. That is thin privilege.

While I was already aware of some aspects of my privilege, the most powerful talk that I attended at the Multi-Service Eating Disorders Association (MEDA) national conference helped me to understand that my thin privilege includes elements I had never before considered. Caitlin Martin-Wagar, an eating disorder clinician and doctoral student in counseling psychology, gave a presentation in which she listed several examples of thin privilege, some of which you may not have previously considered either:

  • Chairs and airplane seats fit thin bodies.
  • Thin bodies are represented in all forms of media.
  • Thin people are never the punchline in sitcoms because of their body size.
  • When thin people go to the doctor, their health concerns are generally taken more seriously.
  • Thin people can buy dolls of similar build for their children.
  • Thinness connotes good morals and positive characteristics.
  • Thin people have an easier time shopping for clothing.
  • Thin people do not have to represent all people of their size.
  • In comparison to larger individuals, thin people receive less unsolicited health/dietary advice or veiled concerns about their health.
  • Employers pay thin people more.
  • Thin people face less scrutiny while eating in public.
  • As a thin person myself, I can write this blog without receiving accusations of being self-serving.

In order to escape weight stigma and in hopes of enjoying the same privileges as thin individuals, some people embark on weight loss endeavors that are most likely to make them heavier in the long run and worsen their health. If we are serious about wanting to help people improve their health, then we have to change our society so that people of all sizes enjoy the same privileges.

Ms. Martin-Wagar offered us professionals some tips regarding how we can combat weight bias within healthcare, but she also shared some ideas for how all of us can challenge thin privilege:

  • Read and learn about the relationship – and lack of relationship – between weight and health (which you can do on our Weight Loss FAQ page).
  • Consider the barriers and challenges of living with a larger body size.
  • Learn from larger-bodied friends about their experiences.
  • Do not make comments about people’s body sizes, shapes, or weight.
  • Be aware of weight bias veiled as concern.
  • Call out injustices as you witness them.

We do not live in a zero-sum game in which treating larger people better means treating thinner people worse. Rather, we can and must work to establish a society in which thin privilege is no privilege at all, just the same rights and respect enjoyed equally by people of all sizes.

 

She Said

This year’s MEDA conference had a number of interesting and informative talks given by experts in the field of eating disorders (ED). Throughout the day, I was heartened to see that the ED treatment community is starting to embrace the principles of Health at Every Size® (HAES) and Size Acceptance. But despite this positive movement, unfortunately what stood out to me this year was that we still have a long way to go in the ED treatment community when it comes to helping those in larger bodies who are suffering from an ED.  

Ragen Chastain, the author of the blog “Dances With Fat” and renowned speaker and advocate for HAES and Size Acceptance, was the keynote speaker on the second day of the conference. Her talk centered on the idea that given the culture that we live in (i.e., one that is fatphobic, diet-minded, and generally not welcoming to people in larger bodies), those who are living in larger bodies and struggling with ED can find it nearly impossible to fully recover as everything in our society tells them that being thin is the most important thing. Ragen’s talk hit the nail on the head, and it was interesting to see many of my colleagues in the audience nodding their heads in agreement with her points. At the end, Ragen received a well-earned standing ovation, and it seemed like everyone in the room was on the same page.

Well, not everyone, it seems. During the Q&A session after her talk, Ragen received a question from one of the ED practitioners in the room. This woman started out by saying that she agreed with everything Ragen had just spoken about, but she had an anecdotal experience that made her question some of Ragen’s points. She went on to explain that her “morbidly obese” brother had struggled with his weight for years, and it had gotten to such a dire point that a number of years ago he had gastric bypass surgery. As a result of this surgery, she contended, her brother’s weight went down and all of his troubling health conditions cleared up almost instantly. She went on to say that while she knows that some gastric bypass patients regain the weight due to “cheating” on their prescribed diets, there are those who maintain their losses and “good health.”

This woman’s sentiments went over like a lead balloon, and there were audible gasps from the audience. Ever the consummate professional, Ragen adeptly navigated this uncomfortable situation. She explained that while there are always some outliers who do well with stomach amputation, there are many more who suffer from complications from the surgery, such as lifelong issues with malabsorption, deficiencies, future surgeries to correct structural problems resulting from the original surgery, and even death. In fact, Ragen went on to say that fatphobia is at the root of the weight loss surgery industry because the medical professionals who advocate for these surgeries view fat people as less valuable; that it is better to risk a fat person’s life by having them get the surgery than letting them stay fat. In other words, the weight loss surgery industry is essentially telling fat people that their lives are not as valuable as those of thin individuals and that it is better to be thin and sick or even dead rather than fat.

While I would hope that this woman was the only one at the conference who held positive beliefs around weight loss surgery, I am not foolish enough to think so. Yes, the ED treatment community is getting better about not pathologizing certain body sizes and understanding that EDs can occur in people of all body sizes. But the fact still remains that we all live in this toxic diet culture that constantly tells us that fat is undesirable and unhealthy, that the pursuit of weight loss by any means is admirable, and that thin bodies are superior to fat bodies.  When you have been marinating in this culture for your whole life, it can be hard to realize your own bias around fat people. My hope is that Ragen’s talk changed some minds that day at the MEDA conference and made people think more about how their own fatphobia contributes to diet culture and undermines recovery for patients with ED.

He Said, She Said: Good for who?

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He Said

Our society’s problematic relationship with food has many elements, one of which is that we make sweeping generalizations and place foods, ingredients, and nutrients into dichotomous groups: good vs. bad, healthy vs. unhealthy, sinful vs. virtuous. When we use language like “good for you” to describe a given food’s supposed impact on our health, who is the “you” to which statements refer? That answer makes all the difference.

Those charged with shaping nutrition policy are faced with an impossible task. They do their best to create guidelines for the general population, but their advice fails much of the group because the truth is that when it comes to nutrition, individualization is a necessity.

In contrast, I have the privilege and good fortune to be able to focus on only one person at a time: whomever is joining me at my counseling table at any given moment. Recent conversations with some of my patients reminded me of just how essential it is to customize nutrition guidance.

For example, one evening I had back-to-back patients, one of whom utilizes whole grain products to her advantage in helping her stabilize her blood sugar, while the other must temporarily avoid such high-fiber food because of his acute gastrointestinal condition. If I had made a sweeping statement about whole wheat bread being “good for you,” I would have failed at least one of them.

Another day, I had a patient who is working to increase his potassium intake for the purpose of improving his hypertension and another patient who has renal disease and is on a potassium restriction. So, is a high-potassium food like cantaloupe “good for you” or what?

A couple of weeks ago, a patient referred to Gatorade as “crap,” to which I neutrally responded by mentioning that I drink it during long marathon training runs. He continued to say that my situation is different than his, which was exactly the conclusion I hoped he would reach when I decided to disclose that a beverage with no redeeming qualities in his eyes actually works quite well for me.

My one-decade anniversary of becoming a registered dietitian is coming up this summer, and during all my years of practicing, I cannot remember two patients who ever came in with the exact same set of circumstances. In reality, our situations are always different, as each of us has a unique set of health concerns, preferences, histories, cultural norms, financial considerations, and all of the other factors that together shape one’s relationship with food.

Instead of dividing foods into dichotomous groups that reflect sweeping generalizations about what is “good for you” in reference to the general population, take a morally neutral and pragmatic approach built on individualization. Recognize that every food has a set of attributes – including taste, cost, availability, nutrient content, and preparation options, just to name a few factors in its profile – that makes it more or less advantageous depending on the circumstances. Remember, the very food that you believe is “bad for you” might be great for someone else.

 

She Said

One of the underlying themes I have found amongst nearly all of my eating disorder (ED) patients is the idea that their ED often started with the intention to become “healthier.” Whether “healthier” meant to lose weight, improve certain biomarkers, or just feel better, these individuals embarked on a restrictive food mission, omitting certain “bad” foods (mostly foods high in sugar and fat) and replacing said foods with “good” foods (mostly vegetables and protein). As harmless as these initial intentions seem at first glance, for someone with ED, they often unravel into something potentially life threatening. 

For my patients with anorexia nervosa, this fixation on “good” and “bad” foods can result in a dangerously low body weight. In addition to extremely low weight, the lack of calories literally starves every organ of the body, including the heart and the brain. Brain scans of healthy control brains versus brains of patients with anorexia show that anorexia literally shrinks the brain. As such, these individuals undergo profound brain changes that lead to decrease in cognitive functioning (due to slowed neuronal growth), depressive symptoms (due to lower levels of neurotransmitters), and a reduction in affect displayed (due to shrinkage of the frontal lobe). What is really insidious about EDs is that they start off in the brain as mental illness and eventually lead to damaging the same brain by means of malnutrition. It is a vicious cycle.

The only way to break this cycle is by refeeding (in addition to therapeutic help and perhaps medication). In this initial stage of recovery, it is imperative that the patient take in enough calories to restore his or her body weight to their healthy weight range. In fact, it is almost impossible for therapeutic measures and medications to really help these patients until their brains are at least back to functioning levels. Many of my patients with severe anorexia struggle with brain fog, have trouble formulating thoughts, and cannot communicate clearly due to brain deficits, and this makes therapy not nearly as effective as when the brain is at least functioning at baseline.

The tricky part about refeeding is that many of the “bad” foods that these patients have been avoiding are, in fact, the same foods that will help them to restore weight most easily. These high carbohydrate/high fat foods are integral to getting these patients to their healthy weight ranges, as they usually have higher concentrations of calories than low carbohydrate/low fat foods. As such, these foods pack a much bigger punch, providing more calories in a smaller amount, making it easier for patients to get what they need while lessening the gastric overload.

Many of my underweight patients who need to weight restore will ask me if they can just eat more of the “good” foods to help them gain the weight back. Aside from heart-healthy nuts, avocados, and nut butters, most of the “good” foods fall into the low carbohydrate/low fat group that provides very few calories for the same volume. In other words, these noncalorically dense foods pack less of a punch, meaning that one would need to eat a much larger volume of these foods to get the same amount of calories that are in calorically dense foods. In order for someone to regain weight, eating large amounts of vegetables and protein is not going to get them to their goal as their stomach will simply prevent them from consuming enough.

What is “healthiest” for these patients is to consume calorie-dense foods and avoid those foods that take up more volume but do not provide the necessary calories. Thus, for the sake of example, a pint of Ben & Jerry’s ice cream is a better choice than a salad for someone who needs to regain weight. We have all been taught that certain foods are always “bad” in every context (ice cream, fried foods, sweets), but the example above shows that it is not so cut and dried. Is a pint of Ben & Jerry’s the “healthiest” choice for someone with high cholesterol? Possibly not. But for someone with anorexia who needs to gain weight, it is healthier. 

In other words, “healthy” is a very subjective term when it comes to nutrition. One size does not fit all as everyone has different health goals and medical conditions. While whole wheat bread might be the better choice for someone who suffers from chronic constipation, it would wreak havoc on someone with diverticulitis and should be avoided.   The “good food/bad food” dichotomy is problematic because it does not take the individual into account. The way we talk about food in our society needs to change.

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.

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.  

“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.