Carbs

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

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

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

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

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

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

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

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

Hold Off On Time-Delayed Eating

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You may have caught a recent New York Times piece entitled “Time-Delayed Eating Leads to Better Food Choices” in which the author writes, “A series of experiments at Carnegie Mellon University found that when there was a significant delay between the time a person ordered their food and the time they planned on eating it, they chose lower-calorie meals.”

Dr. Eric VanEpps, the post-doctoral student who led the research, elaborates, “If a decision is going to be implemented immediately, we just care about the immediate consequences, and we discount the long-term costs and benefits. In the case of food, we care about what’s happening right now – like how tasty it is – but discount the long-term costs of an unhealthy meal. [When we order a meal in advance], you’re more evenly weighing the short-term and long-term costs and benefits. You still care about the taste but you’re more able to exert self control.”

Self control, unhealthy, lower-calorie . . . Based on the language Dr. VanEpps uses and the undercurrent of a good/bad food dichotomy, time-delayed eating sounds like yet another dieting tool right up there with drinking a glass of water before sitting down to a meal, consuming caffeine to stave off hunger, or not eating after a certain time of evening. We all know by now that dieting rarely works, right?

Regarding the research at hand, two of the pieces discussed in the New York Times article are hidden behind pay walls except for their abstracts. While I can only comment on what I am able to read, the information available to me leads to many important follow-up questions.

What happens when the time comes to eat and the food you ordered long ago does not meet your intuitive needs in the moment? Will you eat it anyway? If not, what is plan B? If you do eat it, might you consume more of it than you really need in an attempt to satisfy yourself through sheer quantity? Will you overeat by beginning your feeding with your pre-ordered food only to follow it up by eating something else that you actually want?

Consider a personal example. A little over a decade ago, I went through a phase where I was modifying cookie recipes in all sorts of ways in an effort to make them “healthier”: nuts and dried fruit instead of chocolate chips, oil instead of butter, whole wheat instead of white flour, reduced sugar, etc. These changes sounded good in theory, but who was I kidding; these “cookies” were only cookies by name and bore a stronger resemblance to pancakes. They never quite hit the spot. When you want cookies, no amount of pancakes will satisfy. Either I ate the healthier cookies by the batch in an effort to quell my cookie craving, or I chased them with traditional baked goods anyway. Now that I make normal cookies full of butter, sugar, white flour, and chocolate chips, I only need to eat one or two in order to feel satisfied.

Consider the short-term and long-term ramifications of time-delayed eating. If you just consumed a meal you did not really want but ate anyway, what happens at the next meal, or later that evening? How do you eat the next day? The next week? The next six months? The restriction/binge cycle of dieting suggests that sooner or later there will be consequences somewhere down the road.

One of my patients is coming off a serious health scare and has completely revamped his way of eating over the last year. On the weekends, his family maps out exactly what they will eat each day of the upcoming week and then they shop only for the ingredients necessary to implement their plan. When Thursday evening rolls around and the dinner entree he scheduled five days earlier no longer sounds appealing, he eats it anyway. He may not love it, but he can tolerate it.

Right now, he does not mind taking a utilitarian approach to his eating. So far, it seems to be working for him, and who knows, maybe it always will, but as his dietitian I have to think ahead to what might happen in the coming months and years as the fear associated with his medical incident subsides and leaves him with a different picture of motivation than the one he holds today. In other words, how long can one tolerate eating foods that may seem healthy on paper, but on the enjoyment scale are only meh?

Similarly, I encourage you to consider the aftermath you are likely to have on your hands if you try time-delayed eating and find yourself trying to reconcile the food you pre-selected for yourself and what you actually want to eat in the moment. If the research teaches us anything, it’s that such discrepancies are a virtual certainty to occur.

An Important Shot Bricked Off the Glass

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KevinLove

If ESPN is going to advertise their story with a provocative before-and-after pictorial of Kevin Love’s body transformation, then let me begin my response by pointing out that the chiseled-armed latter version of Love is arguably a worse player than his earlier, pudgier self.

Sure, now that Love is LeBron’s sidekick in Cleveland rather than the focal point of offense in Minnesota, one might expect some of his numbers to be down. However, his points per game, rebounds per game, and assists per game have all worsened despite nearly identical minutes per game and playing in the midst of what should be his peak basketball years. That’s tough to do. Given that, someone will have to explain to me why we are focusing on his physique instead of his noteworthy and curious decline.

That someone, however, might not be Jackie MacMullan. Normally a fantastic sports journalist, one of the best in her field, she took a shot at an important subject with her ESPN article entitled, “From Kevin Love to Draymond Green, NBA players struggle with food more than you think,” but uncharacteristically threw up a brick.

Her piece begins with a detailed account of Love’s meticulous and rigid eating habits. “Not 10 almonds, not 18 almonds — 14 almonds,” his trainer reports. “Kevin is exactly on point. If he’s supposed to eat every two hours, then on the days when he wants to sleep in, he’ll wake up, eat and go back to sleep.” Even his teammates raise their eyebrows at his eating behaviors, which also include bringing his own food on the team plane rather than “be tempted by a postgame spread that might be high in calories and carbohydrates.”

The aforementioned content and the article’s title set up perfectly to discuss disordered eating, which is sorely in need of more attention and dialogue. “NBA players, in truth, are just like us,” the author writes, before listing various eating behaviors common to both professional athletes and laymen. A glaring omission from her list is that professionals are susceptible to dysfunctional relationships with food, eating disorders, and nutrition myths just like the rest of us. Sometimes abnormal behaviors are so prevalent that we mistake them as normal, and I think the author may have fallen into that trap.

More troubling is that instead of discussing Love’s eating habits as a red flag of concern, the author presents them in the context of his lower weight and improved endurance. Consider the impact this kind of message has on readers. For you parents out there, do not be surprised in the least when you walk into the kitchen and find your teenager counting out his or her almonds.

Furthermore, while Love is no doubt eating in a way that he believes serves him best on the court, we must remember that professional athletes often focus on the here and now while long-term risks take a back seat. The stakes are simply different for them. Professionals put their long-term health on the line for short-term rewards that are unavailable to the rest of us. Love just rushed back on the court from a concussion so he could continue playing in the NBA finals. If you suffered a similar concussion, would you risk permanent brain damage in order to play out the remainder of your YMCA rec league’s spring season? Similarly, readers must understand that following an eating plan as rigid as Love’s is risky and makes little sense for the general population.

The author turns her attention to Oliver Miller, “. . . who at his peak weighed over 375 pounds, ate so much of it [pizza] that the Suns took drastic measures, including hospitalizing him and hooking him up to IV fluids. ‘But then they found out he was ordering Domino’s from the hospital,’ [former teammate Danny] Ainge says. ‘They had to put a security guard outside the room.'” Under a photograph of Miller is a caption reading, “Oliver Miller had to be hospitalized because he couldn’t keep his eating under control. The root of his career-long battle? Pizza.”

Look, I have never met Oliver Miller or viewed his medical records, but whatever was going on with him during his playing days, I promise you that the root cause was not pizza. By talking about pizza, or any other specific food, in this way, the author further propagates the myth of food addiction. When we abandon the diet mentality, uncouple moralization from eating behaviors, break up the good/bad food dichotomy, build intuitive-eating skills, and make trigger foods available in abundance, “food addiction” typically resolves, which is the exact opposite outcome that an addiction model would predict in response to such treatment.

Even if Miller was suffering from binge eating disorder, which, as with other eating disorders, is a mental illness that gets played out through food, pizza is still not responsible for his struggles. More importantly, neither you nor I know whether or not he had such a disorder. Hopefully, one of our takeaways from our shameful treatment of Pablo Sandoval over the winter is the lesson that we cannot determine someone’s relationship with food or the presence of an eating disorder based on his or her body size or weight. The notion that we can is yet another myth.

“But it’s not as easy as simply losing weight. Becoming lighter, in many cases, often doesn’t translate into peak performance,” the author later writes. While I completely agree, the article’s subsequent content seems tenuously related at best. She discusses Roy Hibbert, who lost weight upon request by one coach and then put it back on when the Pacers hired a new coach who asked him to regain it, but that was apparently related to differing philosophies in team play between the two coaches, not a change in Hibbert’s performance. A more direct and relevant example would have been to discuss Love’s aforementioned regression despite his body transformation.

The article’s most important passage reads, “Dallas Mavericks coach Rick Carlisle says the one thing he has learned in his 27 years in the league is not to judge a player by his body type. Mavericks guard Raymond Felton, for instance, is more diligent about his diet than Russell Westbrook, yet you’d never know it by a simple eye test.” So true, but these 54 words are drowned out in a 2,910-word article largely about dieting and weight. Besides, in an age in which attention spans seem to rarely exceed 140 characters, how many readers even make it far enough in the article to reach this important paragraph?

While I commend the author for taking on this topic, her article could have been so much more than it is. She could have brought to light the societal prevalence of disordered eating, eating disorders, and nutrition misinformation so widespread that they infiltrate professional locker rooms. She could have explored how the eating habits of star athletes impact the general population, especially minors. She could have addressed the dangers and damage stemming from coupling weight with performance. Instead, she did none of those.

Ms. MacMullan, an important story is begging to be written here, and I believe you can still author it. Please consider grabbing your own rebound and putting up another shot.

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.

He Said, She Said: Weight Watchers – Helping You Lose Since 1963

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He Said

We believe that people should have the freedom to choose whichever healthcare paths they wish to take, independent of whether or not we would recommend their selected treatment plans. Disclosure and transparency are corollaries necessary for building a foundation that supports patients as they make decisions regarding their own care. Today’s approaches are likely inferior to healthcare’s future toolbox, and part of what separates respectful collaboration from a sales pitch is candidly discussing both the pros and cons of available options so patients can make informed decisions. We are not afraid to admit “I don’t know” when that is indeed the most appropriate response. None of this makes us exceptional or great, but it does make us honest.

For a look at the flip side, consider Weight Watchers®. A magician once explained to me his secret: misdirection. He gets you to fixate on his right hand so you entirely lose track of what his left hand is doing. Weight Watchers uses ads emblazoned with their “Because It Works” slogan to capitalize – literally and figuratively – on your desire to lose weight while they hope you forget to ask for their definition of “works.” The large font in their television ads demands so much of your attention that you miss the fine print resulting from the Federal Trade Commission’s (FTC) action against Weight Watchers in 1997 that declared they must concede that “For many dieters, weight loss is temporary.” In reference to the commonplace weight regain that prompts clients to re-enroll in the program time and time again, Richard Samber, Weight Watchers’ former financial director, explained, “That’s where your business comes from.” Weight Watchers is profitable, in other words, because it can successfully create short-term weight loss and make you believe that their long-term failures are actually your own.

Weight Watchers distracts you with their glittery new SmartPointsTM system and hopes you will ignore the long list of previous systems, including the Weight Watchers Program Handbook for Ladies, the Quick SuccessTM Program, the original PointsTM program, and PointsPlusTM, that never worked nearly as well as they wanted you to believe at the time. Weight Watchers is not changing their program because “Now we’re enhancing our program based on the latest science,” as their Chief Scientific Officer, Gary Foster, wants you to believe; nor are they changing their program because they suddenly uncovered data showing its poor efficacy. This is not a case of “When we know better, we do better.” They knew for decades that their program was not working as well as their large print made you believe, but they continued to promote it anyway, and when forced by law to tell the truth, they wrote it so small that you probably missed it.

Despite their spin that Weight Watchers always worked and now they are just making it even better, Weight Watchers is changing for one reason: money. Over the last four years, the company has seen their stock plummet from $85.00 to $6.80 per share as customers and potential customers have turned instead to weight-loss apps or more holistic approaches. To combat the former, they are launching a new mobile app and an expanded coaching program that offers more extensive support outside of group meetings. Their response to the latter involves some sleight-of-hand trickery. “Beyond the Scale” appears to be the new slogan, replacing “Because It Works,” and their company logo has been tightened up to two letters, thus removing the word “weight.” Seeing as they are so poor at creating long-term weight loss, taking the focus off the scale would make sense, but it is just a surface-level marketing ploy. Taking a closer look reveals that weight is still the focal point of their approach.

A Weight Watchers spokeswoman recently told Good Morning America, “People would really spend a lot of time trying to figure out ‘How do I get my Doritos in? Oh, I can do it if I adjust this and adjust that.’ Now it’s not as important for them to make sure how they are getting their Doritos in. It’s much more important for them to say, ‘What am I putting in my body? How’s that going to make me feel?'” Sounds very similar to intuitive eating, or at least a perversion of it warped just enough so at first glance it appears to fit seamlessly with their weight-centered approach.

The problem is that intuitive eating and dieting mix as well as oil and water. In fact, the very first principle of intuitive eating, as stated by Evelyn Tribole and Elyse Resch, is “Reject the Diet Mentality.” Sure, some people pursue intuitive eating hoping to lose weight, but intuitive eating is not designed to be a weight-loss tool, and if someone is unable to at least put weight on the back burner, then he or she will never truly learn to eat intuitively. In other words, having one foot in intuitive eating and the other in weight-loss culture will likely get you nowhere.

Really think about the company name: Weight Watchers. Weight. Watchers. People who watch weight. How is someone possibly supposed to jump with both feet into intuitive eating in the context of weigh-ins and an emphasis on mass? It is fine and dandy for Foster to say, “[Weight] is an important metric, but not the only metric,” but when the scale continues to be the focal point and the most important measure of progress in the eyes of everybody involved, consider the bind clients will find themselves in if and when becoming more proficient with intuitive eating is at odds with the scale. With the attention still on weight, how long will it be before the newly developed intuitive-eating skills are abandoned in favor of old-fashioned restriction?

Weight Watchers launched a pilot study of their revamped program in New Jersey, and 38 of the 40 participants lost weight, including three women whose testimonies of having lost between 18 and 50 pounds were featured in the Good Morning America segment. “We still produce weight loss,” Foster said on the show. Pretty much any kind of restriction will lead to short-term weight loss, so it always blows my mind when companies act like their program is unique in this way. Remember, nobody knows how to produce long-term weight loss in more than a tiny fraction of people who attempt to achieve it. The right hand can attempt to distract you with all sorts of glowing testimonials and a small, short-term pilot study, but none of that suggests that this version of their program will work any better than its predecessors, and you know the left hand is still holding the FTC-mandated disclaimer due to the futility of the program.

Weight Watchers certainly has success stories, and they make sure you never forget it. Group meeting leaders are all former clients who have lost weight and kept it off (at least so far) through a combination of behavior change and a boatload of factors out of their control that happened to work in their favor. Their mere presence is a subtle sales pitch that conveys enticing testimonies of hope and success, making you believe that the next winner could be you if only you continue to partake. Weight Watchers emphasizes seduction over expertise and downplays that leaders do not necessarily have backgrounds in nutrition, exercise science, or anything remotely connected to health, but rather disciplines such as drama that lend themselves to charismatic performance. Why hire someone with solid and extensive qualifications in economics and finances to manage your money when you can instead attempt to follow in the footsteps of some dude who struck it rich on a convenience store scratch ticket?

The other issue with their use of leaders and celebrity spokespeople to pitch their product is that neither you nor I know for sure what they do or do not do behind closed doors in order to achieve and maintain weight loss. Both parties have incentive to keep their weight in check regardless of the costs. Leaders can lose their jobs if they regain weight, and my understanding is that celebrity endorsement contracts are contingent on continued weight maintenance. Behaviors kept private can range from the privileged (personal chefs, personal trainers, etc.), to the deceitful (employing other weight-loss techniques beyond the Weight Watchers program being credited), to the disordered (ever-increasing restriction and/or exercise, preoccupation with food and physical activity, social withdrawal), to the outright dangerous (very-low-calorie diets, unregulated supplements, eating disorders). Clinically, we have seen many patients whose eating disorders were triggered by competition in a weight-based sport such as crew or wrestling, participation in an appearance-based activity such as gymnastics or figure skating, or employment in a size-based field such as modeling or personal training. While I do not believe we have ever had a Weight Watchers leader or celebrity spokesperson as a patient, it stands to reason that they are similarly vulnerable to the emphasis placed on their weight and the pressure to maintain it.

For 52 years, Weight Watchers has deceived you by knowingly overstating the efficacy of their programs and blaming you for their own failures, all at the expense of your time, money, and health. Do you really want to bet your resources and well-being that the outcome will be any different this time around? You deserve more than smoke and mirrors, don’t you?

 

She Said

While this might be news to some of you, it’s been nearly two months since Oprah Winfrey announced that she has not only become a member of Weight Watchers (WW), but she has also bought 10% of the company and become a board member and adviser. According to O, she decided to join and later invest in Weight Watchers as she has “always struggled with weight” and was impressed by the company’s “holistic approach” to health and weight loss. On Ellen DeGeneres’s talk show (which aired on October 23rd), Oprah reported that she had already lost 15 pounds since August 12th and was truly enjoying the program.

Oy. Where do I start with how sad this whole situation is? I have always been a fan of Oprah, as I have seen her as a strong advocate for women, someone who has been through a lot in her life and who wants to help young girls and women become their true and best selves. While the media often focused (and still focuses) on her weight gains and losses, I was always impressed by her ability to bring people together, inspire, and educate. Oprah is so much more than her weight!

I remember in 2010, I was so excited to see that Oprah was having Geneen Roth on as a guest of her show to discuss Roth’s best-selling book “Women Food and God: An Unexpected Path to Almost Everything.” Roth’s philosophy is that the way one eats is directly related to one’s core beliefs about being alive. She is an anti-diet proponent who posits that by exploring one’s spirit and soul, one can break free from emotional eating, finding balance with one’s relationship with food and one’s body. On the show, Oprah was giving such high praise to Roth and her book, saying how she was inspired to “never diet again” and that this book was a life-changing read for her.

So that brings me to the present day. Really, Oprah? What happened? Because last time I checked, WW is a diet, a set of externally based rules that tells its members what and how much to eat in order to lose weight to become socially acceptable – pretty much the opposite of Roth’s message. As we have written about too many times to count, 95% of people who alter their diet in order to lose weight will regain the weight and usually end up heavier. Weight Watchers is no different – it is a diet! Whenever anyone tries to tell me that it is a “lifestyle,” not a diet, I really have to contain my eye-rolling reflexes. Want to figure out if you are on a diet? Here’s how: Are you purposefully manipulating your food intake based on a set of external (i.e., not internally based) eating rules? Is your main goal of said food manipulation to watch the number on the scale go down? Well, I hate to break it to you, but you are on a diet, my friend. And chances are, even if you do end up losing weight, you will regain that weight and then some.

In a purely monetary sense, Oprah’s investment in Weight Watchers is brilliant – contrary to its popular “It Works!” slogan, It Doesn’t! The company has admitted that the success rate of its members is embarrassingly low, and much of their research is based on data that was collected over the span of a year. Um, nice try! We all know that weight regain often occurs between 1 and 5 years post-diet. But of course Weight Watchers doesn’t have data that goes that far. What a surprise. The company’s business plan is so clever because it knows that the diet doesn’t work. 95% of their members will regain the weight (blaming themselves instead of the diet, of course) and will rejoin, creating an unending cycle of profit for Weight Watchers.

Listen, I don’t really blame Oprah for making this truly unfortunate decision – she is human, and she is not immune from the body-shaming, weight-loss messages women receive on a daily basis. But I am disappointed that she is choosing to participate in and endorse a company whose sole purpose is to tell women that they are not enough, that their worth should be measured by a piece of metal, and that weight loss is the only way to find one’s true and best self. Oprah, I really expected more from you.

“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.

The, umm, “power” of carrot cake

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CarrotCakeOn Valentine’s Day, I surprised Joanne by baking her a carrot cake. Just over one week later, I realized half the cake was still in the refrigerator. Although we liked it, we both felt like we had had enough. The cake was getting old and we did not want to take up freezer space with it, so we pitched the remaining portion.

In posting this, I risk the inherent danger of misunderstanding, so let me be clear: Moralizing foods or eating behaviors is a harmful practice that I do not endorse. Carrot cake is not “bad” or “unclean” or a “guilty pleasure,” nor did I “fall off the wagon” when I baked and ate it. We are not “disciplined” for leaving some, nor would I have been “good” if I had never made it in the first place.

Our carrot cake exemplifies a nutrition strategy that Joanne and I oftentimes use with our patients. We often hear people tell us about their trigger foods, i.e. foods they feel must be completely avoided because a little inevitably turns into a lot. They are addicted to these foods, they say, or perhaps they blame themselves and cite a supposed lack of willpower.

The presumed solution is to abstain from these foods at all costs, but the downsides of this approach include missing out on favorite foods, a low likelihood of long-term success, and reinforcing the notion that these foods are taboo, which only serves to make people want them more.

We find that doing quite the opposite works better: Keep large quantities of said trigger foods on hand at all times and give ourselves permission to eat them whenever we want. Patients sometimes bristle when we raise this idea. If we believe a food has control over us, then having it available in abundance feels scary. Furthermore, giving ourselves permission to enjoy it whenever we feel like it sounds ridiculous and counterproductive to the pursuit of health.

I know, I know, we’re crazy, but think about it: Granting ourselves unconditional permission to eat a particular food does not automatically mean we are actually going to eat it regularly or in vast quantities. We may be surprised to find how sharply our desire for a previously-taboo food can drop off once we give ourselves unconditional permission to consume it.

We couple this approach with building intuitive-eating skills, which involves learning to ask ourselves questions about how hungry we are, what food do we really want at the moment (what temperature/color/texture/flavor/etc. do we really feel like), and what quantity of the identified food do we truly need to feel satisfied. If we ask ourselves these questions in a neutral, open-minded, and non-judgmental fashion, the answer is only sometimes going to be the previously-taboo food.

When it is, then we eat it slowly, enjoy it without guilt, and get on with our day. We stop when we have had enough, not when we are overly stuffed, because we know we can have more if and when we want it. The food, in essence, is demystified. Cookies are just cookies. Potato chips are just potato chips. Bread is just bread. We only experience their power over us when we operate in a paradigm that gives them power. When we remove moralization, judgment, and strict rules from the model, the sham of power is exposed for what it is and supposed addictions resolve. The carrot cake is forgotten as it blends in with all of the other foods in the fridge.

Joanne and I keep lots of play foods on hand, much of which we never touch. We have apple crisp ice cream that I bought this past fall in our freezer and Halloween candy in our pantry. We have unopened trays of Newman’s Own cookies and stashes of frozen pastries I made from scratch. We still have Valentine’s Day candy – from last year’s Valentine’s Day.

And none of that makes us “good” or indicates “willpower” or “discipline,” nor are we “bad” or “weak” or “guilty” when we do enjoy these foods. By having play foods on hand at all times, we find that we actually want them less. Remember, carrot cake is just carrot cake. Sometimes it hits the spot, but other times we might just want, well, a carrot.

Intuitive Eating

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Thanks to a colleague’s tip, one counseling technique I sometimes implement is a one-on-one book club of sorts where a patient and I read a book together that is relevant to his or her care. Recently, I have been reading Intuitive Eating with a patient who is working hard to overcome decades of approaching eating from the vantage point of dieting and to build a new relationship with food.

He has impressed me by how open-minded he is to a new way of looking at eating and by how candidly he has shared the thoughts, questions, and concerns that have come to mind during his reading. Now about a third of the way through the book, he reports that he sees himself in many, but certainly not all, of the case studies that the authors present. However, the idea of not depriving himself feels scary. Specifically, he notes that he loves having dessert, but that he is better off skipping it because one brownie so easily turns into four. Besides, he says, health must come into the picture somewhere, so there must be a “but . . .” caveat to the notion of not depriving oneself. He is waiting for the other shoe to drop.

His concerns are common among people who are at the early stages of putting aside the dieting mentality and learning intuitive eating. He is right that we certainly consider health. After all, I am a licensed health care practitioner. Before we take into account the hard science of nutrition though, we have to address the emotions that affect eating.

Sure, physiological mechanisms exist that yield pleasure when we consume foods that are high in fat, sugar, or salt. You are alive to read this because these mechanisms gave your ancestors an evolutionary advantage and they passed them down to you. However, the reason that one brownie turns into four has less to do with physiology and more to do with the morality that gets attached to them.

When we experience guilt for eating a particular food or virtue for abstaining from it, these emotions block us from being able to truly experience and honor the internal cues that our bodies give us regarding our eating. We eat the first brownie, feel guilty for having done so, and say “screw it, today is ruined” and then reach for three more. In essence, the idea of not depriving ourselves feels scary because in our minds it translates to opening the flood gates. In other words, brownies all day, every day.

In reality, that is not how the body tends to operate. When we strip away the morality of food and see our choices on a level playing field, we discover that the appeal of previously-forbidden foods drops considerably. Some days we may want an apple for dessert, other days we may not feel like dessert at all. And what if we go through the question tree of asking ourselves are we hungry, how hungry are we, what texture/temperature/color food do we want, do we feel like something salty, savory, or bitter, and how much of that food do we really need to be satisfied, and we determine that a brownie will indeed do the trick? Then we find the best brownie we can get our hands on, eat it slowly, enjoy every bite, stop when we are feeling satisfied, and know that we can have another one whenever our bodies are asking for one.

Ideally, the hard science of nutrition comes into play after this sort of relationship with food is established. We can talk about the advantages of one kind of cereal over another, or one kind of yogurt over another, or what have you, but we have to take into account the human element. Whole wheat bread is probably a better choice for someone with high cholesterol than is white bread, for example, but if forcing down the whole wheat because it has a better nutritional profile on paper is going to trigger some sort of overeating in search of satisfaction, then he or she is probably better off just having the white bread in the first place and getting his or her soluble fiber someplace else. On the other hand, if the two breads are pretty much equally enjoyable, then sure, he or she is probably better off with the whole wheat.

Learning to eat intuitively involves taking a leap of faith that we can largely trust our bodies to tell us what and how much to eat. Reestablishing that trust involves dialing down the noise of guilt and virtue that makes our internal signals difficult to hear. If you find yourself consuming piles of brownies, or none at all, consider whether or not you are truly listening to your body.