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.

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.

Veganism

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Veganism has been gaining some traction in the diet world lately. While it sounds harmless enough and even “saintly” to forgo meat, chicken, fish, eggs, dairy, honey, gelatin and the like, I have found that the client’s motives behind going vegan are quite important to figure out when meeting with them initially, as sometimes they can indicate some disordered eating.

For some people, the draw of veganism is purely moral – they do not feel right about taking life (or products) from any animal. In other cases, environmental concerns top the list of reasons why someone might choose a meatless diet because meat production has been found to contribute to pollution via fossil fuel usage, water and land consumption, animal methane, and waste. And of course, there are those who really do not enjoy the taste or texture of meat/fish/poultry/pork and their products. In all of these examples, the individual is making food decisions based on personal preference. Everyone has the autonomy to choose what foods to feed themselves, as that is part of being a human – we can choose what we eat.

What concerns me the most about veganism is the zeal with which some vegans talk about their diet. I don’t want to generalize to the entire vegan community because I know many vegans who do not behave this way, but I have been struck by how many celebrities, actors/actresses, “health experts,” and social media personalities have seemed to paint veganism as the only moral and healthful way to eat and that those who are not vegan are less than/going to an early grave/behaving immorally or selfishly, etc. This is very problematic for me because I believe that shaming others about their food choices is detrimental to their health mentally, psychologically, and physically – not to mention that not everyone can afford to follow a vegan diet due to socioeconomic status, the availability of fresh produce, and other factors.

Another concern I have with veganism is how it can sometimes indicate an underlying eating disorder (ED). Many of my patients with EDs have tried to eliminate whole groups of food from their diets, and for some of them, going vegan is just another variation on that theme. Of course, it is often difficult to suss out what is really going on when someone goes vegan, but if it coincides with increased preoccupation with weight, rigidity or secrecy around food or eating, and other signs of trouble, it is worth taking note of it.

Going vegan is not for everyone. About a year ago, I was working with a young woman who identified as a vegan. She said that it felt like such a part of her identity that the alternative (i.e., eating animals or animal products) seemed impossible and undesirable. This young woman was part of the vegan community, and she strongly identified with the morals and values of this group. For her, it was as much a lifestyle as it was a way of eating. At the same time, however, she complained of physical symptoms, including lack of energy, dizziness, weakness, difficulty concentrating, and weakened immune system, and she wondered if perhaps her vegan diet wasn’t working for her body. After much discussion in my office (Mind you, I did not encourage her to eat meat, just to weigh the pros and cons.), the patient decided to try to reintroduce meat into her diet to see if it made a difference in her physical symptoms. Over the course of a few weeks, she began to slowly add in some animal products and found herself feeling much more energized, clearer, and healthier overall. Of course, there might have been a placebo effect at play here, and we can’t be sure that simply adding back in some meat/animal products “cured” her, but the difference was startling. Despite this, the patient felt very conflicted about giving up veganism because it would mean losing a huge part of her identity. In the end, she decided to continue to eat meat occasionally, essentially becoming a “flexitarian” – someone who sometimes chooses to go meatless but other times will eat meat. This compromise seemed to work best for her physiology.

I believe that anyone considering becoming vegan needs to really weigh the pros and cons of this decision. Why are you going vegan? Is it because you feel it is morally wrong to eat animals and their products or that it is harmful to our environment? Do you feel like your body works/feels better eating this way? Or are you using veganism as a way to further limit your diet, restrict, and try to manipulate your weight? Are you able to make sure you are getting enough protein, iron, vitamin B12, and calcium (nutrients that are more difficult to get through a vegan diet)? Is this way of eating sustainable for you or more of a hardship? In the end, everyone has the right to decide what and how they eat. But it is always a good idea to consider the factors that go into these decisions.

He Said, She Said: Menu Calorie Counts

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He Said

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

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

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

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

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

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

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

 

She Said

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

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

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

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

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

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

Politics

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Shortly after we published our March e-newsletter, I received an automated notification informing me that one of our readers had unsubscribed. His given reason: “your political bias – no thanks.”

The only overt political statement we made is that we had followed through on our promise to donate all of the co-pays we collected between Thanksgiving and New Year’s to the Southern Poverty Law Center (SPLC), an organization that fights hate, teaches tolerance, and seeks justice. Huh, I wonder which of those missions our reader objects to the most?

Anyway, at first I felt bad, as if the loss of a reader indicated a shortcoming on my part. Maybe I had crossed a line of some sort by bringing politics into our work.

On the other hand, fuck that. Acknowledging that nutrition is political and declaring what we stand for is important for our practice’s identity.

Nutrition is science, and science, as recent times have reminded us, is political. A couple of weeks ago, I participated in the Boston March for Science. Take a moment to steep in the ridiculousness that is having to stage a protest in hopes that our current leaders will incorporate evidence into their proposed policies.

Nutrition is healthcare, and healthcare, as Republican efforts to destroy Obamacare have reminded us, is political. Today, the House voted for the American Health Care Act, which – if enacted – will result in the loss of health insurance for millions of people and hasten death for many of our fellow citizens. The American Medical Association has condemned the Act, while I remember would-be patients who were unable to receive treatment because their insurance refused to pay. I think to myself: This is only going to get worse.

Nutrition is cultural, and our culture, as we have known for years, is political. Regardless of her intentions, Michelle Obama’s support for the “war on obesity” made our societal focus on weight that much more glaring. Our current, umm, leader’s objectification of women and admissions of sexual assault, for which millions of voters inexcusably gave him a free pass, are exacerbating matters. In an effort to flee weight stigma and oppression, people run towards a diet culture that damages relationships with food, increases eating disorder risk, and – ironically – promotes weight gain and worsened health.

Politics are not just about which bubbles each of us fill in on election day. Our positions reflect how we move about the world and what we want not just for ourselves, but for our friends, neighbors, strangers, the generations that will come after us, and of course our patients.

Nutrition is political, and our stances regarding the latter are intertwined with how we approach our work. We believe that everybody – regardless of their gender, size, weight, religion, country of origin, wealth, lifestyle behaviors, ethnicity, language, mobility, or sexuality – is deserving of respect, informed consent, and affordable access to evidence-based healthcare as a matter of human rights.

Emotional Eating

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Last week, I received the following email from one of my patients:

“I wanted to touch base about a concept that keeps coming up in food podcasts/books/articles, etc. The idea of ‘emotional eating,’ and what that even means. I understand that it is the idea of food being comforting and thus using it as a coping mechanism, but isn’t food almost always tied with emotion (happy, guilty, satisfied/pleased, disappointed, etc.)?

“I think this concept is referring to eating when not hungry to deal rather than other ways, but often I hear rethinking if that cupcake in the middle of the afternoon is what you need or to call a friend or go for a walk.’ Yes, I agree that sometimes if I am tired, I will crave these foods, and realize I just need a nap. However, what if I crave a sweet snack in the middle of the afternoon, after lunch, because I am hungry and that’s what I want? To be honest, I don’t love this idea because it feels judge-y. Am I interpreting it wrong?

“Also, on a Friday after a long week, I look forward to a drink, a meal of my choice, and some popcorn in front of the TV. Does that make me an ‘emotional eater,‘ too? I don’t think that is wrong but maybe this is not how I should be coping with stress…? Thanks!”

“Emotional eating” is a buzzword phrase that seems to be everywhere lately. Many of my patients come to me to help them stop “emotionally eating” because they see it as a problem or a failure on their part. I thought it might be a good idea to explain what I believe emotional eating is and what it isn’t and whether it should be seen as problematic or not.

From the time that we are babies, feeding (i.e., via breast milk or formula) is one of the very first ways our parents/caretakers take care of us and show us love. Feeding and eating are primal actions that serve as a way to keep us alive; we depend on our caretakers to help us with this at the beginning. When a baby is hungry, he or she will cry, and the caretaker will provide nourishment to take away the feelings of discomfort from hunger and give the baby satisfaction. This basic hunger-crying-feeding-satisfaction loop happens over and over again and basically cements itself in the infant’s brain that the only way to get rid of one’s uncomfortable hunger is to cry until mom or dad gives the infant nourishment. This way, a very strong connection is forged between food and love as our caretakers are the first ones in our lives who provide both of these necessities to us.

As we grow up, food and eating situations are often connected with emotions. For instance, you might have very strong and fond memories of your grandmother’s apple pie and how lovingly she served it to you on special occasions. Or perhaps you remember how your dad used to make you the perfect peanut butter and jelly sandwich for school every day, cutting off the crusts just so, and how this made you feel loved and special. We collect these eating/emotion experiences throughout our lifetime, and as a result of this, we can elicit some of the above emotions by eating some of the associated foods.

I believe that while eating can often be associated with emotions, it does not necessarily need to be problematic. When most people nowadays use the term “emotional eating,” I believe they are referring to the behavior of trying to cope with negative emotions or situations by eating comfort food in the absence of hunger. In my opinion, someone occasionally dealing with their emotions by eating is not a big deal, but if it becomes a chronic habit that is bringing discomfort or pain and/or not truly helping to assuage that person’s negative emotion or situation, that would be something to be curious about in a very neutral and self-compassionate way. It’s important to realize that feeding ourselves comfort food sometimes even if we are not hungry is one way that we are trying to take care of ourselves. It might not be the most helpful or effective way to give ourselves self-care, but it is a self-care attempt nonetheless.

In response to my patient’s thought that food is “almost always tied with emotion,” I would say that many eating situations are not necessarily connected with emotion. For instance, I had an apple and a piece of cheese for snack today, and while it was tasty and satisfying, I didn’t have any emotions associated with it. I also think one can crave a cupcake in the afternoon for no other reason than it is what they are humming for at the time. It doesn’t have to be emotional.

At the end of the day, “emotional eating” is something that nearly everyone engages in from time to time. In and of itself, it doesn’t need to be a problem, but if it becomes the only way that you cope with negative feelings or situations and it is bringing you distress, it would be worth it to try and develop other coping strategies (with the help of a therapist) to deal with these feelings/situations in a more constructive manner.

He Said, She Said: Clean Eating

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He Said

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

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

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

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

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

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

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

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

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

 

She Said

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

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

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

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

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