Tag Archives: health at every size

Thoughts on the 2016 Multi-Service Eating Disorders Association (MEDA) Conference

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On May 14th, I attended the 21st annual two-day conference held by the Multi-Service Eating Disorders Association (MEDA). This year’s conference theme was “Thinking Outside the Body: Empowering Yourself, Your Clients and the Community.” I was only able to go to day two of the conference, but I feel like I learned a lot during that one day of presentations and thought it would be helpful to summarize some of what I learned.

The first talk I attended was the day’s keynote address, “Gender Identity, Gender Expression, and Eating Disorders,” presented by Carly Guss, MD, Allegra Gordon, MPH, ScD, and Jerel Calzo, PhD. Obviously, the topic of gender identity has been on the forefront of many people’s minds given the latest legislation around transgender individuals being able to use public restrooms. While I am familiar with transgender issues, I have only worked with one transgender individual in my practice, so I was very interested in hearing what the presenters had to say on the matter.

While the presenters gave a helpful primer on gender identity, their main focus was on the prevalence of eating disorders (EDs) in the transgender community. According to the presenters, two recent studies found that compared to cisgender heterosexual women, transgender men and women have 4.6x odds of past-year self-reported ED, were more than twice as likely to have used diet pills and purging in the past month, had 4.8x risk of being “underweight,” and had 2.5x risk of being “obese”.  Two other studies on ED risk in the transgender community found that the majority of participants (transgender men and women) reported a history of disordered eating and that there was a “strive for thinness” to suppress unwanted secondary sex characteristics, particularly in people who were gender assigned “female” at birth but identified as males. It makes a lot of sense if you think about it – if one were to identify as a male but were born female, that person might want to prevent the development of curves and beginning of menstruation that naturally occur as a girl becomes a woman. Restriction and maintaining a very low body weight can prevent these developments from occurring.

My takeaway from this talk was that it is important for practitioners to be aware of the challenges that transgender individuals face in our society (particularly in healthcare) and their increased risks for EDs and body-image issues. It also made me examine my own practices when working with transgender clients, including how to make them feel most comfortable (e.g., using the client’s preferred pronoun[s] and having gender-inclusive language on our patient forms) and incorporating the best strategies to help them recover from their EDs.

The second talk I attended was “What You Need to Know about Trauma and PTSD: A Personal and Professional Perspective for Working with Eating Disorders.” The first presenter was Jenni Schaefer, a very well-known figure in the ED community. Ms. Schaefer is a self-described individual who has fully recovered from an ED and has written a number of books on her recovery journey. What I (and perhaps many others in the audience) was not aware of was that Ms. Schaefer is also a survivor of trauma. Her presentation was quite an eye-opener as it described how her trauma and ensuing Post Traumatic Stress Disorder (PTSD) were impacted by and complicated by her ED. This part of the presentation was especially illuminating for me, as I have a number of patients who have been victims of trauma and struggle with both PTSD and EDs. The second presenter was Luana Marques, PhD, and she discussed the different therapeutic options for patients struggling with both disorders. While the content was not exactly geared towards registered dietitians, it gave me some insight into how PTSD can affect recovery from ED and vice versa.

After an hour lunch break, I was thoroughly excited for the third talk of the day. As many of you know, Jonah and I identify as Health at Every Size® (HAES) practitioners and are supportive of the size acceptance movement. Well, we were absolutely thrilled to learn that Ragen Chastain (blogger at Dances with Fat), a world-renowned , self-described fat activist and proponent of “behavior-centered health,” was going to be presenting on both HAES and Size Acceptance in her talk entitled “The World is Messed Up, You are Fine – Helping Clients Deal with the Culture of Body Shame.”

Ragen gave an absolutely electrifying talk about how our society gives extremely damaging messages about our bodies via the medical community, the media, and even our politicians (e.g., Michelle Obama’s fight on childhood “obesity”), and how these messages can make recovery from an ED very difficult. She started the presentation by giving a quick primer on the principles of HAES and Size Acceptance, stressing the point that people of all body sizes have the right to exist and that healthy habits are more likely than body size to determine healthy outcomes.

After this introduction, Ragen displayed a number of images taken from popular magazines and websites, each showing how the media tries to manipulate celebrities’ appearances by using Photoshop. All of these manipulations aimed to make the subjects appear thinner and younger, perpetuating the idea that everyone (especially women and girls) are only beautiful if they are young and slender. A number of years ago, I never would have thought about how these images are manipulated, but now in my work with ED clients, I am super sensitive to how these images can be extremely damaging to girls and women, and I often suggest to my clients that they avoid certain magazines and publications for fear of triggering negative body image thoughts.

Ragen continued on to talk about the role of HAES in ED recovery and how important it is for ED healthcare providers to give consistent body positive messages that counteract the negative, fat-phobic messages that our patients receive every day. She gave examples of how practitioners could create a safe environment for their ED patients, such as providing a space that includes positive representations of diverse body sizes, creating “body affirming” spaces by having chairs that can accommodate people of all sizes, and being aware of our own beliefs and assumptions around weight and size.

While I was familiar with nearly everything Ragen discussed, for I am an avid reader of her blog, it was interesting to observe those in the audience who were hearing this information for the first time. There were a number of thought-provoking questions that were posed during the Q and A section at the end, and Ragen adeptly answered all of these queries with the grace and presence of someone who is confident as well as extremely knowledgeable about the topic on which she was presenting. Her talk finished with a standing ovation from the audience, something that I have rarely witnessed at any of the MEDA conference presentations I have attended. It was truly a special moment.

The presentation that followed Ragen’s was called “Taking the ‘Th’ Out of #Thinspiration – Utilizing Social Media to Encourage, Empower and Bring Hope to Those Battling or In Recovery from Eating Disorders”. The first half of the talk was presented by Donald Blackwell, a man whose own daughter had suffered from an ED and who himself became very active in ED recovery. Mr. Blackwell’s part of the presentation centered on the many different social media platforms that people use today. While I am already quite familiar with Facebook, it was helpful to learn more about the other commonly used social media vehicles, including Twitter, Tumblr, and Instagram, and how they are used in pro-ED (people who believe that EDs are “lifestyle choices”, not illnesses) as well as ED-recovery circles. I have always been aware of the numerous pro-ana (promoting anorexia nervosa [AN]) and pro-mia (promoting bulimia nervosa [BN]) websites out there, but this talk gave me an even clearer picture of the amount of harmful information that circulates on the internet.

The second part of the presentation was given by Joanna Kay Mercuri, an ED sufferer who is now in recovery. She went into even more detail about the pro-ED websites and their content as well as the pro-recovery websites and what they focus on. Ms. Mercuri also discussed her own blogging and how it helped her in her recovery, as it gave her a platform to discuss her feelings and struggles while connecting with others. The end of the talk centered on how we as a society can actually respond to the pro-ED social media and bring the pro-recovery content front and center. All in all, this talk was helpful in showing the influence and use of social media platforms regarding EDs, and it gave me a lot of insight into what my patients might be seeing online possibly every day.

The conference’s endnote address, “Overview of ARFID: Avoidant/Restrictive Food Intake Disorder,” was given by Ovidio Bermudez, MD. It was very interesting to learn about this relatively newly recognized group of disorders as it has recently been added to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). ARFID is defined by the Center for Eating Disorders as an “eating or feeding disturbance as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:

  • Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
  • Significant nutritional deficiency.
  • Dependence on enteral feeding or oral nutritional supplements.
  • Marked interference with psychosocial functioning.”

Those struggling with ARFID are not the same as those with AN or BN, as ARFID sufferers typically have no fear of weight gain and no body image distortion. Instead, individuals with ARFID are those who, due to a problem with eating, aren’t able to take in enough nutrition through their diet. Some examples of eating problems are difficulty with digestion of certain foods; strong aversions to colors, textures or smells; no appetite; or being afraid to eat as a result of a frightening episode of choking or vomiting. Sometimes individuals with ARFID can develop BN, AN, or other EDs, but not in every circumstance. I myself have worked over the past few years with several clients who have struggled with ARFID, so I found this talk most helpful in recognizing the signs and symptoms, treatment plans, and prognosis.

All in all, I found my day at the MEDA conference one filled with interesting ideas, helpful tips, and above all, support from my fellow colleagues. These types of conferences are not only a wonderful opportunity to reconnect with familiar ED treatment practitioners, but they are also a terrific time to meet the “new kids on the block.” I look forward to returning to the MEDA conference next year, for I am sure I will learn even more!

The Tipping Point

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You probably heard about Gina Kolata’s piece in the New York Times earlier this month detailing commonplace weight regain among Biggest Loser competitors, but you may have missed Dr. Sandra Aamodt’s excellent follow-up piece in which the neuroscientist shares research showing just how unlikely long-term weight loss is for any of us, not just the show’s former contestants.

While this information might be news to some of us, data showing commonplace weight regain among people who attempt to lose it has been available for quite a while, yet it has not garnered much mainstream attention despite years of efforts from researchers, advocacy groups, activists, and practitioners around the world, including myself.

Regardless of what our goals are, nobody wants to hear that they are probably unattainable, which partially explains why the myth of weight loss has survived. Unfortunately, yet understandably, people are reluctant to listen when receiving a message they do not want to hear.

The problem, however, runs deeper. The notion that we can lose weight and keep it off if only we try hard enough has taken on “everybody knows” status. We hear it in our fitness centers, around the proverbial office water cooler, up in the bleachers at Little League games, and at spring cookouts. The message is so commonplace that we do not stop to question its validity.

Doctors, dietitians, and other healthcare practitioners can inadvertently contribute to the mess. We are human and vulnerable to the same “everybody knows” paradigm too, and sometimes we take treatment guidelines at face value without looking into them for ourselves.

Lump the green version of myself in there as well. I shake my head with embarrassment and shame at some of the advice I doled out early in my career before I knew better, and I wish my profession as a whole would get up to speed.

We see the “success stories,” the people in our lives who were able to lose weight and keep it off, at least so far. The Massachusetts State Lottery website features pictures and stories of its recent million-dollar winners, but their enticing smiles do not change the reality that the most likely outcome of buying a ticket is financial loss.

Children observe their parents looking critically in the mirror, associating guilt and virtue with eating and exercise behaviors, and oscillating between rigid restriction and binges. The torch of dieting and weight obsession passes to the next generation.

If the myth of weight loss dies, so do the $60,000,000,000-per-year diet industry and the privilege enjoyed by the thin in a culture thick with fat shaming and weight stigma. They keep the fantasy alive and have plenty of incentive to make sure we continue to feel bad about ourselves.

Cognitive dissonance is a powerful force to overcome, not just for laymen, but for everyone. Given the strong headwind, I am pleased to see this information finally receiving the widespread attention it so desperately needs.

Ms. Kolata and Dr. Aamodt certainly deserve credit for their parts, but so does everybody who has ever made an effort to get the word out – practitioners and researchers who risked career suicide, activists for whom death threats are a daily way of life, and patients who have stood up and demanded evidence-based care – as they have also contributed to what I hope is finally the tipping point.

An Iatrogenic Condition

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Joanne and I were watching Shark Tank the other night and I found myself wondering if the negotiations and business analyses might be so bogus that venture capitalists and MBAs get a good chuckle out of the reality show. Maybe real estate agents, general contractors, and interior designers watch Love It or List It and shake their heads. Since these programs cover topics outside my area of expertise, their content could be spot on or largely misleading and I might not know the difference.

Yesterday, the New York Times exposed the Biggest Loser for some of the long-term harm it does to its contestants and the unrealistic expectations it sets for viewers. Most notably, weight regain is pervasive despite the ex-contestants’ best efforts to keep it at bay.

For myself and other practitioners who use a similar approach to ours, some of the minutiae may have been new to us, but generally speaking, the Times piece went right into our “Yeah, no sh-t” folders, as we have known the show to be fraudulent and problematic since its inception.

Having said that, it occurs to me that for readers whose expertise lays elsewhere, this might have actually been news. If that includes you, and you were surprised to learn about the contestants’ weight regain and struggles, I hope you do not feel gullible. How were you supposed to know?

However, any seasoned obesity or metabolism researchers who found themselves surprised by these results ought to be embarrassed. Data showing commonplace weight regain among people who attempt to lose it has been available for quite a while. Even some of the most ardent weight-loss supporters reluctantly admit that although we have several methods of inducing short-term weight loss, we have no idea how to produce long-term weight loss for more than a tiny fraction of the people who attempt to achieve it.

What we see more commonly, not just in Biggest Loser contestants, but in people across the board who attempt to intentionally lose weight, is ultimate weight regain that often exceeds their baselines.

As an example, consider the following growth chart, which is from a real patient of mine (All information that could possibly reveal her identity has been removed.) Looking at her chart, hazard a guess as to when her parents and doctor first attempted to intervene with her weight. Do you think it was at age 17, when she first came to see me?

Example

No, it was just after age eight, when her BMI-for-age, which was in the 92nd percentile at the time, was deemed a problem. She was naturally a bigger kid, okay, but this fact’s implications have more to do with stigma than health. The focus on weight and a belief that an intervention would help to lower it created an iatrogenic condition. In other words, her weight became a problem because it was viewed as one.

Not only was the diagnosis off base, but the attempted interventions worsened the problem. The first diet produced a slimmer 10-year-old, who subsequently rebounded into a chunkier tween. Based on the research, this was to be the most likely result. As the patient’s teenage years began, subsequent attempts to lower her weight produced similar patterns of weight gain.

They took a child in the 92nd percentile and dieted her up to the 99th percentile, and in the process screwed up her relationships with food, her body, her doctor, and her family, all of which she is now working hard to untangle and fix.

None of that was the child’s fault, nor are the parents to blame, for they were just doing what they thought was right by following instructions from trusted practitioners.

And really, I do not blame the doctor either. Pediatricians and other primary care doctors are tasked with a tremendous responsibility to maintain basic knowledge about a myriad of conditions, everything from sore throats, to sexually transmitted diseases, to early signs of cancer, but this very demand limits them from being experts in any one field, including weight regulation.

The chain of education and direction has to begin somewhere. While these data on Biggest Loser contestants might have come as a surprise to laymen, the researchers who are responsible for the foundation of our healthcare policies should have seen them coming. That it took a New York Times article to wake them up is shameful, but they sure seem to be paying attention now, at least for the time being.

He Said, She Said: Exercise as Penance

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He Said

Data are only as useful as our understanding of them. Food labeling represents an opportunity for education while simultaneously illustrating the tremendous challenge of conveying complex ideas in a space only slightly larger than a postage stamp.

The nature of my work is one-on-one counseling, and as such, public health policy is not my area of expertise, but I can still recognize when those charged with such decisions are barking up the wrong tree. Such is the case with Britain’s idea to indicate the exercise load necessary to burn the calories in a given food.

First, remember that proclamations of calorie content are often flawed. Earlier in my career, I created nutrition labels for a university dining service as well as for cooking software. The labels that I produced reflected my best estimates based on other people’s estimates of generalities. Food manufacturers utilize a similar process to create their labels, and laws that allow rounding further cloud the picture. As the game of telephone teaches us, inaccuracies creep in with each step we take further away from the source.

Second, despite what activity trackers and cardio equipment dashboards would have us believe, estimations of caloric expenditure are similarly problematic. Your soda can may inform you that you need to run for 15 minutes to burn off the calories contained within, but this overgeneralization does not take into account your age, size, body composition, running mechanics, exercise intensity, course terrain, or any of the other variables that impact the energy that you as an individual will expend during a specific 15-minute bout of jogging.

Third, even if the data for calories consumed and burned were as accurate as can be, the implied calories-in-vs.-calories-out paradigm is an oversimplification of the complexities affecting weight regulation and overall health. Our eating and physical activity behaviors do matter, of course, but they are mere pieces in a puzzle mainly comprised of factors that are out of our hands.

Last, the presentation of a tradeoff between eating and physical activity reinforces a commonly held and problematic notion that food choices are worthy of punishment and exercise is our penance. As I recently told BuzzFeed and the Daily Meal, the good/bad food dichotomy, so prevalent in our society, links issues of morality, virtue, and guilt to our eating behaviors and is counterproductive. Nutrition and exercise activity have enough variables already without confounding them further with judgment.

A healthy relationship with food and physical activity means uncoupling moralization from such behaviors, not reinforcing the bond.

She Said

Earlier this month, Jonah and I were watching NECN when a news story came on that made us both cringe. Apparently, Britain is considering creating new food labels that not only tell the consumer how many calories are in the food, but how long the consumer would need to exercise to “burn off” that food. The proposed label would look like this: next to the calories that are listed for the food, there would be two stick figures of a person walking and running. Underneath those stick figures would be the number of minutes that someone would have to engage in either walking or running to negate the calories they consumed.

I find this idea to be highly problematic for several reasons. Firstly, as Jonah and I have written about before, the idea of “calories in, calories out,” is very much oversimplified. Most people believe that if an individual eats an extra 500 calories per day, that individual will have gained a pound of fat after a week. Unfortunately, it isn’t that simple. Numerous studies have shown that everyone processes calories differently, with some individuals getting more calories from the food they eat and others getting fewer calories from the same amount of food, resulting in some people gaining weight and others not gaining a pound.

One such study looked at identical twins and weight gain. Each pair of twins was fed an extra 1,000 calories per day for 100 days while under close observation (i.e., they were confined to a closed section of a university dorm). What the researchers found was that while the twins in each pair gained (or did not gain) the same amount of weight, there was a huge difference between the sets of twins. For instance, one pair of twins gained more than 29 pounds by the end of the intervention, while another pair only gained about 9 pounds. The conclusion that was reached was that some people are more efficient calorie burners, while others are more efficient at storing extra calories.

Aside from the fact that every body processes calories differently, I also take issue with the idea that one should be concerned with “burning off” what they are eating. In my work with people with eating disorders, there are quite a few individuals who engage in exercise bulimia. This means that these individuals will binge and then will try to compensate for the binge by over-exercising. It is a debilitating disease, and I believe that these labels would exacerbate symptoms for these individuals.

Finally, as I have written about before, I believe that exercise should not simply be viewed as a way to burn calories or to “right our wrongs.” Rather, as the Health at Every Size® principles suggest, physical activity should be a way for us to connect with our bodies by engaging in activities that we enjoy. Instead of torturing oneself in the gym to repent for last night’s cake, how about enjoying a walk outside in the sunshine to improve one’s mental, physical, and emotional health? Instead of calculating how many minutes one would need to log on the treadmill to “undo” a cookie, I think it is much healthier to use exercise as a way to feel more alive in our bodies rather than as a weight control tool.

Zootopia

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Generally speaking, Zootopia is a really nice Disney film. As Joanne and I were walking out of the theater and talking about how much we both liked it, she turned to me and said, “There was only one thing about it that bothered me, and I am guessing you know what it is.” Sure enough, I did, as the same problem had caught my eye as well.

The main reason I like the film is because it teaches some wonderful lessons about having the courage to be different, break down barriers, and acknowledge and overcome prejudice. However, the writers missed an opportunity to apply these same themes to body size and instead reinforced widely-held stereotypes about larger individuals.

Although the film does feature characters of various shapes and sizes, both protagonists are stick thin while the rounder characters are generally presented in a more negative light, such as the main character’s portly father, who in his first scene explains how he was too afraid to go after what he really wanted in life and settled for one spent as a carrot farmer.

The most glaring example is Officer Clawhauser, a large, dopey, and disorganized character often shown with food or in the act of eating. An early scene in the film portrays him as so messy and oblivious that he is unaware that he has a donut lodged in his collar.

How ironic, and unfortunate, that in a film that is largely about breaking down stereotypes, Disney glaringly reinforces one. The writers probably never even considered there might be an issue with this because the sad truth is that in a society in which we generally reject stereotypes based on race, religion, ethnicity, or sexual orientation, we inexplicably tolerate those based on body size that are no more accurate than the others, yet are just as abhorrent.

If you bring your children to see Zootopia, consider using the occasion to talk about body size and its associated prejudice. The film does a solid job of teaching that not all prey animals are cowardly, predators need not be savage, and the symbolism contained therein about the human race, but it misses an opportunity to shut down the stereotypes that heroes must be thin and larger individuals are glutinous, lazy, or unkept. This is where you, the parents, can come in and complete the lesson.

Objective / Subjective

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Numbers. Nutrition and exercise are full of them. We can tabulate calories and grams, measure portion sizes, count servings, and analyze food journals. Thanks to various electronic gadgets and apps, we can keep tabs on our steps, estimate our metabolic rate, and track other biomarkers.

As a guy who holds a degree in mathematics and used to work as a research analyst, nobody loves objective data more than I do. When I began my career transition and was moonlighting as a personal trainer, I made use of several physical tests – the Rockport walking treadmill, the sit-and-reach, the list goes on – to quantifiably track my clients’ progress over time. My career as a dietitian started off similarly, as I relied heavily upon bioimpedance analysis data, weight, and estimated macronutrient needs to guide my nutrition advice.

Imagine my surprise when, through a combination of additional education and experience, I realized how little these quantitative data actually matter. On the first day of the first nutrition course I ever took, the professor began with a brief survey of the social, cultural, personal, and financial factors that influence eating behavior. In our diet-minded society in which food is thought to be just fuel and any persuasions to the contrary are seen as weaknesses and sources of guilt, we easily forget how important this basic truth really is.

One of my patients recently told me that his wife purchased a diet book that emphasizes the glycemic index and she would like the two of them to begin eating in accordance with the author’s guidelines. Objectively, the glycemic index, which is a measure of how quickly various foods raise blood sugar relative to a standard (usually white bread), makes some sense. If a food breaks down more slowly, we stay full for longer, eat less, and consequently lose weight. At least, that is what the book’s author wants its readers to believe. Just aim for the low-number foods on the glycemic index chart and we are all set.

Right around the same time my patient told me about this book, another patient relayed to me an experience he had regarding hamburger buns. His parents typically made burgers on whole wheat slider buns that he thought were okay – not great, not awful, but okay – and he normally ate two or three burgers as the meat from the normal-sized patties jutted out beyond the rolls’ perimeter like a UFO. For reasons that remain a mystery to my patient, his mother decided to make burgers on normal white buns one evening. In contrast to their whole wheat counterparts, these white buns hit the spot. He had one burger, felt satisfied, and stopped eating. Turned out that for him, the white bread, which is sky high on the glycemic index, was actually the better choice and kept him from overeating.

The more I work with my patients, the more I am reminded of how the subjective is often of greater importance than the objective, that the qualitative usually trumps the quantitative. Numbers still have their place, for sure, but they really only play a supportive role. This, I have learned, is one of the most significant differences between nutrition on paper and nutrition in real life.

Healthcare For Some

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Yesterday I ran the Five College Realtors 10-Miler, which was my first event since last summer’s surgery and my first road race since September 2013. My time was well off my personal record for this course, which I set the last time I ran it in 2007, but I have been through quite a lot in the last nine years so expecting to pick up where I left off would have been unrealistic. Besides, it was just great to be able to race again regardless of what the clock said.

As I have written before, I owe a debt of gratitude to everybody who has helped me recover over the last two-plus years, but at the same time I think others who do not receive the same level of care from their own support systems, including their medical teams.

When I went to my primary care doctor in late 2013 complaining of back pain, I received orders for x-rays, an MRI, and a CT scan, referrals to see a physical therapist, a physiatrist, and multiple surgeons, and a collaborative discussion about the pros and cons of complementary treatments, such as acupuncture, chiropractics, massage, and neuromuscular therapy. Subsequently, I received a topical medication, oral medicines, injections, and referrals to more surgeons. Ultimately I required an operation, and then another one, more scans, and physical therapy that continues to this day.

When my “overweight” patients go to their doctors complaining of back pain, more often than not they report receiving one intervention and one intervention only, one that research shows is only achievable for a tiny fraction of the people who attempt to attain it and may not improve their condition even if they do: a directive to lose weight.

Are we not all deserving of thorough, collaborative, evidence-based healthcare, or just those of us who are thin?

He Said, She Said: “I want to lose weight”

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He Said

When faced with “I’ve got some good news and some bad news,” most people seemingly prefer to hear the latter first. With that in mind, let us first look at the results of weight loss pursuits before coming around to the opportunities we have for change.

Short-term and long-term weight loss are two entirely different animals. The ease with which short-term weight loss is promoted creates false expectations for long-term weight loss. Pretty much any kind of restriction (Paleo, Weight Watchers, gluten-free, low-carb, low-fat, weighing/measuring portions, following a scripted meal plan, commercial meal substitutes, etc.) performs about the same: initial weight loss followed by regain that often surpasses the baseline weight. The overall body of research suggests that pursuit of intentional weight loss is approximately 12 times more likely to result in ultimate weight gain rather than loss.

The patients who come to me looking to lose weight often have similar stories. They list the various diets they have tried over the years before disclosing “and now I am the heaviest I have ever been in my whole life.” Frequently, they look back on their body size and shape from before the first diet, the body they were unhappy with at the time, with a new longing, like an empty-handed gambler wishing he had put his coins to better use rather than wasting them in the slot machine.

While their reasons for wanting to lose weight vary, they are all valid and understandable in the context of our society in which weight stigma, size discrimination, diet culture, and misinformation are so prevalent. These unfortunate realities bleed into our healthcare system and can influence otherwise-great doctors to recommend weight loss rather than evidence-based treatments.

The good news is that the underlying reasons for wanting to lose weight are oftentimes attainable if we pursue them directly rather than using weight loss as a proxy. Whether your goal is to improve your blood pressure, lower your cholesterol, control your blood sugar, perform your sport better, our build a fabulous wardrobe, or anything else along those lines, your likelihood of success is much higher if you put weight to the side and go for your goal head-on.

 

She Said

Weight is a heavy topic (pun intended) in my work with eating disorders. Even though I put a lot of effort into making sure that weight is not the focus of my work with patients, inevitably, it will come up. Usually, my patients express fear around the possibility of gaining weight by eating intuitively (or by following a meal plan). In addition to this fear of weight gain, many of my patients also desperately want to lose weight. When the patient is in the “overweight” or “obese” BMI category (a completely bogus way of measuring one’s health), the discussion of losing weight is particularly tricky. Oftentimes this patient will come into my office with a recommendation from their doctor to lose 10% of their body weight in order to improve their health. This, coupled with society’s belief that “everybody knows that being heavy is unhealthy,” also complicates matters considerably.

When a patient comes to see me with hopes that I will help him or her lose weight, I often feel like the Grinch. As I try to explain to them that weight is not a measure of health, that one can be heavy and healthy (or thin and unhealthy), and that society’s fear and hatred of fat is a real thing, I can see their eyes glaze over. And then, when I talk about how 95-98% of all intentional weight loss attempts (via diets) result in weight regain, sometimes I can see panic in their eyes. You see, even though “everybody knows” that diets don’t work, many people believe that if they just try hard enough and if they really, really want it, they can be part of that 2-5%.

As Jonah and I have written about too many times to count, we practice from a Health at Every Size® (HAES) perspective. This means that we believe that health is a multifactor concept that cannot just be boiled down to how much someone weighs. We believe that when someone eats in a nourishing, pleasurable, and intuitive way, when someone engages in physical activity that feels good to their body, when they manage their stress, get enough sleep, avoid smoking, manage health conditions with the help of a health professional, etc., that they can achieve health regardless of what the scale says. Weight only gives us a tiny bit of information about the person. It can tell us something is amiss if there is a large shift either up or down (unintentional weight gain or loss), but otherwise, by itself, it really cannot tell us if someone is healthy.

Another thing I talk about with my patients is that bodies are supposed to come in all shapes and sizes. Even though our society might disagree, some people are just meant to be larger than others. It’s in our genes. We all have a set weight range where our weight would naturally settle in if we ate and moved intuitively. While we might have some ability to move up or down a couple of pounds within this weight range, trying to go outside this weight range takes extreme measures. Our bodies fight these extreme measures in every way possible, but for 95-98% of us, we will return to our set weight range, regardless of whether or not we continue dieting.

But in our society, being heavy is seen as a weakness in someone’s character, that he or she is lazy, undisciplined, and reckless with their health. People make assumptions about others based on their weight, and it seriously stinks. So when an “overweight” or “obese” patient comes into my office desperately wanting to lose weight, I get it. No one wants to be seen as lazy, weak-willed, or stupid. My hope is that someday soon society’s views about weight will shift and that people will start to understand that we all have different genetic makeups, and that while weight can tell us what our relationship with gravity is, it cannot tell us whether someone is healthy, happy, or worthy.

“Real” Science

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Some of you may or may not know that one of my favorite activities is solving crossword puzzles. Not just any puzzles, mind you, but the Sunday New York Times crossword found in the very back of the magazine. Every Sunday, I eagerly sift through my newspaper and find the magazine, ready to start working on the puzzle and figure out all of those elusive answers. This week, as I was thumbing through the pages, I came across an article under the “Well” section of the magazine, which caught my eye: “Mind What You Eat: Can ‘intuitive’ eating be as effective as calorie counting?” written by Gretchen Reynolds. The picture accompanying this article was that of a corpulent, blind-folded man, whose stomach was feeding itself a piece of pizza.

Given the nature of the work that Jonah and I do, I was intrigued to see what Ms. Reynolds had to say about intuitive eating, especially since the idea of intuitive eating is still relatively unknown to most of the general public. As I read on, however, my curiosity turned to disappointment and frustration. The article was riddled with inaccuracies, and, above all, truly missed the point of what intuitive eating is all about.

Although the idea of intuitive eating (also called the “non-diet approach”) has been around for many years, Evelyn Tribole and Elyse Resch, two registered dietitians, brought the topic to the public’s attention in their 1995 book “Intuitive Eating.” In the book, the authors explain the 10 Principles of Intuitive Eating, including such ideas as “Reject the Diet Mentality,” “Honor Your Hunger,” and “Make Peace with Food.” The authors assert that by following these principles, an individual can create a healthy relationship with food, mind, and body. The basic “rules” of intuitive eating are quite simple: eat when you are hungry, eat what you are hungry for (not what someone else or some diet is telling you to eat), and stop eating when you are satiated.

While the book does discuss the likelihood that by eating this way one will reach their “healthy weight,” it is in no way meant to be a diet book or a how-to weight loss treatise. One’s “healthy weight” is not based on the BMI or what popular culture says is healthy – it’s the weight that one’s body arrives at when he or she is engaging in healthy behaviors such as eating intuitively, engaging in pleasurable physical activity, and managing stress.

Since weight loss is not the ultimate goal of intuitive eating, I was confused as to why Ms. Reynolds decided to compare the approach with calorie counting to see which resulted in more weight loss. In addition to this, the article was flawed in a number of ways.

Ms. Reynolds begins her article by saying that intuitive eating has not been studied extensively by researchers. This statement could not be further from the truth! Per the Intuitive Eating website, there have been over 40 studies which have looked at the health benefits of intuitive eating. According to Ms. Tribole who posted her reaction to Ms. Reynolds’ article on her own Facebook page, “last month a systematic review was published on Intuitive Eating with 24 studies, totaling over 9,000 people.”

Ms. Reynolds’ article goes on to discuss a study in which 16 overweight men and women were split up into two groups of eight: one group was assigned to a restricted-calorie diet between 1,200 and 1,800 calories per day, while the other group was to engage in intuitive eating. At the end of the study, which ran a total of six weeks, the researchers found that those in the calorie-controlled group lost more weight than those in the intuitive eating group. Given these results, posits Reynolds, limiting one’s calories is a more effective way to lose weight than engaging in intuitive eating.

Yikes. This article is problematic for a number of reasons. Firstly, the study itself is a poor one to use, as it has an extremely small sample size of 16 subjects and is conducted over a measly six-week time period. Secondly, to draw any conclusions about health outcomes from this study is wildly irresponsible. And thirdly, duh, of course the calorie-restricted group lost weight! This study literally gives us no useful information!

We all know that going on a diet results in weight loss for the vast majority of people. The question is: how likely is it that those individuals will actually keep the weight off for a significant period of time? Given that we know that approximately 95% of people regain the weight they lost through dieting, I’m willing to bet dollars to donuts that all of the individuals in this silly little study regained the weight they lost during the first six weeks of the study. In fact, I wouldn’t be surprised if they ended up heavier than when they started!

I guess the thing that bothers me most about this article is how it completely misses the point of what intuitive eating is all about. Intuitive eating is about eating in a way that promotes one’s health, not in a way that is meant to result in weight loss. Ms. Reynolds reinforces the diet mentality of the general public by her assertion that cutting calories is what is necessary to reach a healthy weight. Articles like this one just create more confusion for Jonah’s and my patients, as it backs up the ideas that weight loss should be one’s ultimate goal and that long-term maintenance of weight loss is achievable.

Stocking

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“I have to get rid of these leftovers or I will eat them all.” Sound familiar? The “them” in question could be leftovers from any holiday celebration that includes food, such as Halloween candy, Thanksgiving pie, Christmas cookies, New Year’s Eve hors d’oeuvres, Easter jelly beans, Memorial Day barbecue, or birthday cake and ice cream.

The aforementioned strategy for dealing with such leftovers sounds logical on the surface and might even seem to work for a little while. If the food is not there, you cannot eat it, right? As the never-ending cycle of holidays continues though, the strategy of avoidance reveals its downsides: stress, anxiety, deprivation, reinforcement of an oversimplified and misleading good/bad food dichotomy, and increased risk for episodes of overeating or outright bingeing.

An alternative does exist, one that takes less mental and emotional energy, allows people the freedom to enjoy holiday favorites without going overboard, and makes peace with food. This alternative is stocking, which is a well-known technique among practitioners who help people with emotional eating, compulsive eating, binge eating disorder, and supposed food addictions.

Stocking is the antithesis of quickly ridding the house of holiday leftovers, and it may initially seem counterintuitive. A full explanation of the technique requires more time and space than would be appropriate for this newsletter, but here are the highlights for your consideration.

Uncouple morality from food and eating behaviors

In order to feel more comfortable with stocking, people need to rid themselves of the good/bad food dichotomy and be able to temporarily put the hard science of nutrition on the back burner. Not all foods are the same nutritionally; it would be ridiculous to proclaim that an apple has the same nutritional value as a Twinkie, and I am not arguing otherwise. What I am suggesting, however, is to strip the moralization away from food. An apple is just an apple; you are not good or virtuous if you select it for your snack. A Twinkie is just a Twinkie; you are not bad, guilty, or weak-willed if you choose it instead. Sometimes your body’s cues will lead right to the apple, other times to the Twinkie, and either outcome is okay.

Establish an abundance of food at home

Identifying what food will feel best in your body means little if you do not have a reasonable shot of providing said food for yourself. Therefore, one of the tenets of stocking is to keep a wide variety at home, including foods that are seen as taboo and can trigger overeating or bingeing.

When our body is asking for a food we do not have on hand, we tend to overeat on the foods that are in the house. This can certainly occur with both adults and children, but we especially see this with teenagers who live in food-restricted households. Well-meaning parents might keep foods high in salt, sugar, or fat out of the house because they think that doing so creates a healthy food environment, but oftentimes it backfires. For example, the teenagers overeat on low-sodium potato chips that never really hit the spot while a small amount of regular chips would have done the trick, or they overeat on Newman’s Own fig cookies when really they just want a couple of Oreos.

Select foods based on intuitive-eating cues

One of the logistical differences between those who practice intuitive eating and those who do not is how food selection begins. Standing in front of the open refrigerator or scouring the pantry and cabinets and selecting whichever foods call to you is an external process that differs greatly from asking internal questions about what temperature, texture, flavor, color, etc., food will feel best in your body at that moment and seeing where it takes you.

These cannot be treated as leading questions. In other words, if you have stocked up on, let’s say, Ben & Jerry’s Cherry Garcia, and you are trying to convince yourself that your body does or does not actually want the ice cream, then stocking will not work. Keep an open mind, ask these questions neutrally, and see where your body’s cues take you.

Maintain the inventory of foods at home, especially of triggering foods

Maintaining the abundance of food in the household is an important element of stocking. If the supply dwindles, you might feel like you need to hurry up and eat a particular food while it is still around. Should you ever run out and then buy it again, the food regains its luster. If you are stocking Doritos, for example, maintain a supply of, say, ten large bags at home. As soon as you finish two bags and are down to eight, go out and buy two more.

Be patient and use a neutral voice

Initially, you may find yourself eating certain foods when your body does not actually want them, but as you keep up the practice, eventually your trigger foods will blend in with all of the other foods in your pantry and no longer sparkle the way they do when they are brand new to the house. Until then, abstain from judging yourself harshly for eating episodes that do not go as you would have liked. Remind yourself that you are still in the early stages of the process and you are learning. With a neutral voice, examine what happened so you can respond differently when similar circumstances arise in the future.

Enjoy your new-found peace with food

Imagine how different your experience with leftover Thanksgiving pie would be if you routinely kept slices of pie in your freezer for whenever your body wanted them. Contrast the fretting you feel about the remaining Halloween candy to the relaxed liberation of always having a few bags of peanut butter cups in the pantry year-round.

For the stocking technique to be successfully implemented, foundational work to dispel nutrition myths, break up the good/bad food dichotomy, and uncouple moralization from food choices is necessary beforehand. Because this process takes time, it is probably too late for the stocking technique to be much help for you this Thanksgiving unless you have already been working on these prerequisites.

The cycle of holidays will continue though, so if you get started now, you might find you have a much more relaxing and enjoyable experience with this February’s Valentine’s Day chocolates than you would have if you continued down your current path.