Tag Archives: health at every size

Dietetics Within the Health at Every Size (HAES) Framework

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Following is an edited transcript of the presentation I gave at the Weight Stigma in Healthcare Settings conference at Massachusetts General Hospital (MGH) on October 18, 2018. The video of my actual presentation is available here.

I have been an MGH patient for a long time. Over the years, I have had three back surgeries here, and the staff has always been amazing. That includes my surgeon, the physical therapists, occupational therapists, nurses, and everybody who helped me during my hospitalizations. Because of the high level of care that I have received here, I feel particularly grateful to have the opportunity to talk with you today. Certainly, this 15-minute talk does not even out everything I have received over the years in terms of give and take, but it feels like a step in the right direction.

My first surgery was over 20 years ago when I was an undergrad at Tufts University, after a preseason physical for the tennis team ultimately revealed a tumor on my spine. After I recovered from the operation and graduated with a double major in mathematics and English, I worked across the river from here as an operations research analyst for the Department of Transportation.

The DOT was a fine place to work, but I realized the field of transportation was not for me. After a period of trying to figure out what I wanted to do with my career, I decided to go back to school to study nutrition at the University of Massachusetts Amherst. Once I completed my degree and my internship over at Beth Israel Deaconess Medical Center, I finally became a registered dietitian, and to be honest, I thought I was going to be amazing. The way I saw it, the basis of nutrition is biology, biology is essentially chemistry, chemistry boils down to physics, and physics is really just math. And who has a math degree? Me. Plus, with my experience in research analysis, and my background in athletics and having worked on the side as a personal trainer, I thought I had all the education and background I needed to be a great dietitian. Calories in and calories out, the Krebs cycle, grams, medical nutrition therapy, energy metabolism, what have you. If they had taught it to me, I had learned it and learned it well, so I thought I was going to be a star.

My initial patients thought I was great, too. They came to me primarily looking to lose weight or to change their body composition, and the vast majority of them did. They were thrilled with their results, some of them called me a “guru,” and they referred their friends.

Everything seemed great, but then I began to notice a pattern. In almost all cases, the initial weight loss plateaued and began to reverse. Maybe it took months, maybe it took years, but the results were almost always the same. My patients looked to me for the answers. After all, I was the one who helped them to lose the weight in the first place. But really, I had no answers. Based on my training, what I was doing should have been working, so what was the problem?

I remember how nervous my patients would be when they got on the scale or on the table for a body composition analysis, but what they did not know was that I was right there with them, as I experienced a really intense internal anxiety, praying that the numbers would be to their liking because if they were not, I was at a loss. Despite the high opinion of myself that I initially had, I began to realize the truth, which was that I kind of sucked at being a dietitian. I got into dietetics because I wanted to help people, and I realized that I was doing nothing of the sort. I felt like a fraud because, honestly, I was. I thought I had all the answers, my patients thought I had all the answers, but the truth was that I had very few of them.

Right around the time that I was experiencing this professional crisis of sorts, questioning everything that I was doing, my wife, who is also a dietitian, was attending a peer supervision group at MEDA, the Multi-Service Eating Disorders Association, so I decided to tag along. We would go around and share our most challenging cases with the group in order to learn from each other and get support that would enable us to better help our patients. When I mentioned that I was consistently seeing weight regain in my patients and I did not know what to do about it, the group leader told me that in approximately 95% of cases, people regain the weight they lose, and in about 60% of cases, people end up heavier than when they started.

My initial reaction was essentially, “Come on, there is no way that is true. If that were true, they would have taught us that in school.” So, I began asking around to other seasoned dietitians I respected, and to my surprise, they confirmed the same. Still, I was skeptical, so they pointed me towards research and articles to back up what they were saying.

For example, according to the New York Times, “After two days of testimony from leading obesity specialists, the panel said it had found no good evidence that any currently popular methods of ‘voluntary’ weight loss had much chance for long-term success. In fact, what evidence the panel could find suggested that 90 to 95 percent of dieters regain all or most of their hard-lost pounds within five years.”

Despite what they taught us in school about calories in and calories out, eat less and exercise more, and all of that, it turned out that nobody had demonstrated that they knew how to create long-term weight loss in more than a small fraction of the people who hope to achieve it. Clearly, I still had a lot to learn.

So, I began talking with more colleagues and doing the reading that they suggested, works like Beyond a Shadow of a Diet, Intuitive Eating, and Health at Every Size. My wife and I became members of ASDAH, the Association for Size Diversity and Health, and networked with colleagues all over the planet who had all come to realize that focusing on weight does not work and were instead utilizing a weight-neutral approach to care with greater success.

Knowing what my wife and I now knew, we wanted to adopt a weight-neutral approach to care, too, and maybe you are thinking to yourself that you have some interest in doing the same – maybe that is what brought you here today – but you probably realize just as we did that it is not that easy to shift gears.

Our professions demand that we further our education, hence continuing education requirements, but when new information makes us realize that we have not been helping people as we thought we were, that can be tough. One of the hardest parts for me was coming to terms with my mistakes and working through the guilt that I felt for having taken patients down a path that turned out to be less helpful than I had expected.

Beyond that, changing approaches risks losing our established patient pool, which risks our livelihoods. Our bills do not suddenly stop coming while we regroup and build up a new practice; the reality is that we all have to keep earning a living.

In a healthcare culture that is very weight focused, announcing that we are taking a weight-neutral approach not only risks losing patients, but also referral sources, our professional credibility, and maybe even our job.

For senior clinicians, including those in managerial roles, change is not easy for them either. Grants, book deals, and clinics can revolve around a given approach and professional identity built up over years and years, and changing direction can risk all of that.

My wife and I are privileged and lucky, in that circumstances and opportunity came together and we had the freedom to change, because certainly not everybody does.

Now that we have changed approaches, we find a weight-neutral approach to nutrition to be so much more helpful and beneficial than a weight-focused approach. Trying to foster long-term weight loss is generally a fruitless task, but by taking a Health at Every Size (HAES) approach, we can bypass that and go directly at whatever someone’s health concerns are.

As examples, if someone has high cholesterol, high blood pressure, or glycemic control issues, we can use medical nutrition therapy to treat these conditions directly, as opposed to attempting to use weight loss as an intermediary.

As another example, if someone is trying to improve athletic performance, we can focus directly on nutrition interventions to improve their performance, rather than hoping that weight loss will bring about increased strength, speed, endurance, or flexibility, when really it might just bring about a nutrient deficiency or an eating disorder.

A fatphobic model is particularly problematic when working with eating disorders, some of which are brought about by concerns about weight and body size in the first place. Trying to tell someone with anorexia that we will help them regain some weight – but not too much weight – reinforces weight stigma and actually colludes with the eating disorder voice, thereby hindering recovery. An approach that incorporates size acceptance, which HAES does, sets the stage for better outcomes.

Now, don’t get me wrong, being weight-neutral, as we are, is different than being anti-weight loss. If someone, through the course of behavior change, happens to lose weight as a side effect and they are happy about that, great, no problem. It’s just that the weight loss is not our goal, nor is it the focus of our work.

When we think of weight bias and the inherent issues with weight-centered care, we often think of the impact on people at the larger end of the spectrum, but the truth is that weight stigma in healthcare hurts thin people, too.

This quote is from a dietitian in Oregon. “I think there are a good number of people at the lower end of the weight spectrum who have undiagnosed sleep apnea. have a friend who was exhausted for years, did lots and lots of testing, and yet because she was thin, they never tested for sleep apnea. And sure enough, that’s what it was…five years later.”

An Australian colleague says, “I know of thin and active people, including a close friend and my physio who weren’t tested for cholesterol, diabetes, hypertension etc. because it was assumed they wouldn’t have an issue when they actually did have very high cholesterol, hypertension, or diabetes.”

According to a therapist practicing in California, “I have also had many clients tell me that because their bodies looked ‘healthy’ their providers would say, ‘Whatever you are doing, keep it up!’ even though they were throwing up, abusing laxatives, compulsively exercising, etc. To a one they talked about how utterly lonely they felt, and how it confirmed that the world did not care about what was really going on with them as long as they just kept up appearances.”

As a thin person myself, I have had doctors make incorrect assumptions about my eating habits because of my size. Whereas fat patients of mine tell me stories about how their doctors give them unsolicited nutrition advice, things like “lay off the bread basket” without even first inquiring about their bread consumption, doctors will bring up nutrition to me only to very quickly stop themselves, citing not my profession, but rather my frame, assuming that I must already be eating as they would have suggested because I am thin.

After my first back surgery, my neurologist cautioned me to “stay skinny,” telling me that if I ever thought about slacking off in terms of physical activity, to remember this conversation I was having with him. I certainly do remember that conversation, as it triggered an exercise addiction that took me over a decade to resolve. All those years, I went to him for follow-up, and he and other doctors missed blatant red flags that I had a problem because the attitude was “You’re thin, so whatever you are doing, keep it up.”

Even though I love my PCP, he is reluctant to order lab work because he sees a thin guy in front of him and tells me “I have zero concerns,” whereas I think of my family history, there are certain markers I want to be keeping tabs on, so every year we go through the same song and dance as we renegotiate what to test.

Professionally, I have had patients assume I know the secrets to getting and staying thin because I am thin myself. This is a huge issue in personal training, too, where our bodies are seen as advertisements for our services. Not only does this create a barrier, in which people who would make awesome dietitians and trainers are wary of entering the field for fear they will not be taken seriously since they do not look the part, but the presence of size-based bias in the room is a hurdle that can hinder care, conjure up false expectations, and mislead patients regarding expertise or lack thereof.

In truth, my size is mainly the product of genetics, privilege, and luck. Despite the overconfidence that I had when I finished nutrition school, the truth is that I still have a lot to learn, and I certainly have no secrets, except for maybe one, which I will share with you now: Some of my colleagues who are much bigger than me, the ones who have trouble getting patients, or referrals, or even jobs – because who wants to see the fat dietitian, obviously they do not practice what they preach, right? That’s the garbage that some people say? – Well, the truth is, the secret is, that these colleagues might be a lot bigger than me, but they are also way better clinicians than me even though I am thin.

“Just tell me what to eat”

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We have no idea what we are doing. As new and first-time parents, Joanne and I are overwhelmed with questions that outnumber our answers. Last weekend, we went out to dinner, just the two of us, and we commiserated regarding our uncertainties, unsolved dilemmas, and seemingly unpredictable behavior and sleep patterns.

“Someone can surely help us with this,” I said, referring to professional help. An expert with advanced education and certifications must exist who has all of the answers, someone who can take control, simplify the picture, and teach us the right way to parent. I paused, realizing the significance of what I was about to say next, and then continued, “I just want someone to tell me what to eat.”

One of my favorite nutrition authors, Alan Levinovitz, is actually a professor of religion, but he has taken to writing about food and eating behavior because he recognizes how themes of spirituality, including fear and a longing for control, are incorporated into how many of us relate to food.

“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,” Professor Levinovitz says. “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.”

And who can blame someone for wanting black and white food rules, a clear and crisp portion prescription, and a list of what to eat and foods to avoid? When we feel desperate and overwhelmed, we just want someone to come along who says they have the answer, the simple solution to our complex problems, and they will tell us what to do. Is that not exactly how I was feeling in the restaurant?

Similarly, who would possibly want to hear that no singular right answer exists, that what constitutes “right” is debatable, and that the situation is complex with several moving parts, some of which are not fully understood or within our power to manipulate? Who wants to be told that no set of rules or rigid structure is likely to produce long-term success, that even the most seasoned experts have gaps in their knowledge and experience? Don’t talk to me about guidelines and trial and error; my daughter is crying, and I need the answer now.

The good news, both for us and for the patients who come into my office, lean back in their chairs, cross their arms, and command, “Just tell me what to eat,” is that help and support are available, even if they are not the sharp and definitive solutions for which we pine. Joanne and I are privileged to have a pediatrician, experienced family members, and other infancy professionals who are all just a text away. While they do not have all of the answers either, we can collaborate and walk the road together.

Similarly, because of nutrition’s complexities, Joanne and I cannot just tell someone what to eat, but we are able to work with our patients to examine the factors that are influencing their eating and then formulate strategies for improvement. Other practitioners can similarly lend a hand. Therapists, for example, can be tremendously helpful for deeper issues that are getting played out through eating behaviors. Answers may be neither immediate or obvious, but together we can figure out a way to move forward.

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.

Holiday Survival Guide

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

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

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

1. Create Safe Spaces

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

2. Have an Ally

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

3. Take Space

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

4. Set Boundaries

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

5. Practice Regular Self-Care

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

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

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.  

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.

He Said, She Said: Clean Eating

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He Said

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

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

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

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

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

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

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

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

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

 

She Said

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

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

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

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

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

He Said, She Said: Whole30®

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He Said

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

She Said

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

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

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

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

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

Sh*t Tennis Ladies Say

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As some of you might know, I am an avid tennis player. After a very long hiatus (like 25 years long), I started playing competitive tennis in several different leagues three years ago. It has been so wonderful in so many ways – I love that I get to play a sport that is not only physically enjoyable, but is also a fabulous social network as well. My tennis teammates are some of my closest friends and I adore them.

That’s why sometimes it feels particularly upsetting when many of them speak in anti-fat, pro-diet, disordered ways about food, weight and body shape. All of these women are intelligent, well-spoken, kind-hearted people. All of these women are liberal, open-minded and generous. And nearly all of these women have either made negative comments about their own bodies, commented on others’ bodies, and have engaged in any number of diets/disordered eating patterns. It is truly mind-boggling. I have decided to write about a few of these comments partly as a way to vent, but I also feel like they can be valuable learning lessons for our readers.

Tennis friend: “Oh my goodness, did you see X on the tennis court today? She has lost/gained a ton of weight– doesn’t she look great/terrible?!”

Why these types of statements are problematic: 1) We have very limited control over our weight – our genetics are the key determinant of our body size. And while we can lose weight in the short-term, nearly 95% of dieters regain the weight, with many of them gaining even more weight than they had lost; 2) There could be a number of explanations for someone’s weight loss/gain – are they going through chemotherapy for cancer treatment? Did they recently have a traumatic life event that significantly changed their appetite? Are they on a medication that is causing them to bloat/lose their appetite? 3) These types of comments reinforce the idea that the most important thing about a woman is her physique. We are so much more than our bodies!

Ways that I choose to respond to comments like these:

“I really prefer not to talk about others’ weight – every body is different and unique.”

“Commenting on others bodies makes me uncomfortable – you really never know what someone is going through. She could have a medical condition we are unaware of.”

“Hey, how about we focus on her tennis game rather than her body shape/size?”

Tennis friend: “I’m so hungry.”

Me: “Oh, I have a granola bar in my bag – would you like it?”

Tennis friend: “Oh, no. I’m dieting.”

Why this is problematic: As Jonah and I have written about too many times to count, diets don’t work long term. When we restrict our intake and actively disregard our bodies’ hunger cues, our body goes into starvation mode. This results in a slowing of metabolism, decrease in energy, and heightened awareness and obsession with food. When you feel hungry, that is your body’s way of telling you it needs fuel. It is not a weakness. It is a necessity, like breathing air and drinking water. Not only that, once someone stops dieting (because the inherent nature of dieting is temporary), that person will likely overeat on high-fat/high-carb foods (which are your body’s preferred macronutrients in times of scarcity), and with their slowed metabolism, the weight will pile back on. Unfortunately, many women engage in this yo-yo dieting, which a number of studies have shown to be more damaging to one’s health than just maintaining a higher weight.

Ways I choose to respond to situations like this one:

“Being hungry is your body’s way of telling you it needs food. I guarantee you will feel so much better if you a eat something. I also bet you would have so much more energy to play tennis!”

“It sounds like you have been on quite a few diets over the past year. I know it’s hard to believe, but it is possible to eat in a non-restrictive way and be healthy.”

“Did you see Serena’s last tennis match? She was eating a snack on the changeover. I think she’s onto something!”

Tennis friend: “My knees/ankles/hips are killing me. If I could just lose these 20 lbs, I know that would fix the problem.”

Why this is problematic: As I wrote about several months ago, focusing on weight loss to cure physical ailments is not the right approach. Yes, biomechanically speaking, weighing less might help one’s knee pain resolve, but there is no guarantee of that. Not to mention, many people of all shapes and sizes have knee/ankle/hip pain (even thin people!). As we age, we tend to lose cartilage, and this often leads to joint pain. Sorry folks, but getting old is unavoidable! There are many ways to help joint pain that don’t involve weight loss (such as quad strengthening exercises for knee issues, medicine, wearable braces). And finally, even if someone were to lose weight to help their knee/ankle/hip pain, it is still highly unlikely they will be able to keep off that weight for any significant period of time.

Ways that I choose to respond to comments like these:

“You know, there are plenty of other strategies to use that could help your ankle pain. I would recommend talking with your doctor.”

“When I had knee pain, I started seeing a physical therapist who gave me a bunch of exercises to try to strengthen my quads – would you like his/her contact info?”

“While weight loss might initially help, it’s nearly impossible to keep off the weight, and it is likely that you will end up gaining more weight in the long run. Maybe you could find some other strategies to deal with the pain?”

At the end of the day, I really do understand why so many of these women make comments like the ones I shared above. And I also know that these comments are not just limited to the suburban female tennis playing community. We as a society have been brainwashed by the media, our doctors, our family and friends to think that it is right and normal to comment on other people’s bodies, to believe that what we choose to eat (or not eat) makes us virtuous or sinful, and to view weight loss as something that is easily achieved and maintained (all of these things being plainly false).  I just wish that we could change the conversation to one about things that really matter, like the state of the world, what we are passionate about, how our families are doing, etc.  Focusing on our bodies and what we put in them is terribly myopic. How much we could achieve if we just changed our focus.

Wishful Thinking

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Last December, I stumbled upon a very interesting article on the website Ravishly. The piece, entitled “Being Thin Didn’t Make Me Happy, But Being ‘Fat’ Does,” written by Joni Edelman, caught my attention for pretty obvious reasons. In it, Edelman included two pictures of herself, one with the caption “Before” and one “After.” As you might have guessed, her before picture is of her when she was at a much lower weight at the age of 35. The after picture is of her and her family, five years later when Edelman was at a much higher weight. Edelman goes on to describe the extreme measures she took to achieve her “physical hotness” displayed in the first photo, including counting calories obsessively (limiting her calories to 1000 per day), exercising excessively (running 35 miles per week), and overall living a very restrictive lifestyle.

While Edelman concedes that being at this low weight came with some “benefits” such as being able to fit into size 4 clothing and receiving positive attention from men, she says that the amount of effort, sacrifice and mental energy it took to maintain this weight significantly diminished her happiness. She found that the time and energy it took to keep her figure ended up taking away from her relationships, especially with her children, as she was preoccupied with her food and working out.

Realizing that “happiness does not require thinness” and “fatness does not presume sadness,” Edelman stopped her extreme dieting and exercise behaviors. As one would expect, she gained weight, and with medication changes to treat her bipolar depression, she gained even more weight. Despite this, Edelman wrote that she had found a “stillness, a joy, and a peace” that she had never had and that “it’s worth 10 pounds.” The article ended with Edelman telling her readers to “be fat and happy. Be unapologetically fat. Wear a bikini, and mean it. Eat pizza and ice cream and enjoy it. Drink up your life and a bottle of wine, and make no apologies.” It was a refreshing article and one that I imagine took a great deal of courage for her to write. In our fat-shaming, thin-exulting world, it’s rare to hear someone (especially a woman) talking about being both fat and happy.

A few weeks ago, one of my patients forwarded me another piece written by Edelman. Apparently, Edelman has decided to start writing a bi-weekly column entitled “Beyond Before & After,” (BB&A) where she hopes to discuss “living without dieting, fostering self-love and healthful choices made on our own terms. No scales, no calorie counting, no before, no after. Because we’re so much more than that.” Sounds promising, I initially thought to myself.

In the first installment of BB&A, Edelman talks about her blog from last December. How she received so much praise and attention for writing so bravely about something that many woman would be afraid to do – to call themselves “fat” and be okay with it. But then the article takes a turn. Edelman writes that even though she fully believed that she could be fat and happy, something started to shift. She describes instances in which her body started to fail her, such as not being able to sit on the floor without falling because she was not able to bend due to her stomach getting in the way. How she was tired of feeling breathless after walking up 13 stairs and how her weight was making it nearly impossible to heal an injured ankle. All of a sudden, Edelman writes that being fat “stopped working for [her],” and that she wanted to change this by losing weight, that “if being fat doesn’t work for you, you can change, or you can at least give it your best effort.”

Oh dear. I don’t know where to begin with this. First of all, this piece makes me sad. Here was someone who was fighting the good fight, who really seemed to get it: that weight and health and wellbeing are not inextricably linked. That there are plenty of thin people with health problems and plenty of fat people with none. Interestingly, Edelman talks about how she got her blood work done (in addition to numerous other health tests) and surprisingly enough, her labs were nearly impeccable, with a low thyroid as the sole issue that arose. Other than this (and being diagnosed with peri-menopause), Edelman was in excellent health. But, even with this positive information, Edelman is resolved to change her body.

Okay, time for some full disclosure: part of me understands where she is coming from. I am also living in a larger body and there are times that I think to myself, “you know, your knee pain and plantar fasciitis would likely improve if you lost weight.” Biomechanically, I understand that carrying more weight translates to more stress and strain on my body. But, then my rational mind kicks in and reminds me of several facts: 1) There are plenty of thin people with knee pain and plantar fasciitis (just ask nearly all of my slender tennis teammates) 2) There are numerous ways to address these health conditions without losing weight (just ask my podiatrist and my physical therapist) and, most importantly, 3) Permanent intentional weight loss is impossible for 95-98% of those who try to achieve it. So, even if losing weight did improve my issues, no one has found a way to keep the weight off. In fact, most people end up gaining even more weight than they had lost in the first place, resulting in an even higher weight.

The other issue I want to shed light on is Edelman’s admission that she has struggled with an eating disorder (ED) in the past (namely exercise bulimia). Even if she is not actively engaging in restriction and over-exercise, her weight loss goal is simply ill advised. Recovery from an eating disorder is a life-long process and it is completely at odds with purposefully losing weight. You can’t be in recovery and be actively trying to lose weight. They are incompatible. Even Edelman realizes how tricky her endeavor is going to be, admitting that she has already been weighing herself more than once a day and has been drinking copious amounts of water to help her feel full. I will not be surprised to see her get back into an ED mindset if things continue this way.

Listen, I get it. Being fat can be tough in our society, and it’s easy to blame our physical maladies on our body size. But just deciding that being fat isn’t working for you and that you are going to change your body permanently is at best wishful thinking and at worst a very dangerous endeavor. I hope that Ms. Edelman figures this out before it’s too late.