Macy’s

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A Reader’s Intuitive Eating Question

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“The concept of intuitive eating is hard for me to grasp. The way I understand it is that I need to listen to my body so I will recognize when I’m hungry, and eat until my body tells me I’m not hungry anymore. If that’s basically correct, my problem is that I’m rarely ever hungry because I only recently ate, and always continue to eat until external clues tell me to stop (e.g. I ran out of time or food, or my eating partner has finished). How can I begin to listen to my body so I know when I’ve become hungry enough so that it’s okay to eat, and when I should stop eating?”

A reader emailed us the question above in response to an invitation in a previous newsletter to suggest future topics. It sounds as if the writer is still working to fully understand the concept of intuitive eating and how to incorporate it into his life, and I hope I can help.

Some of the language that the writer uses caught my eye: need, enough, okay, should. Diets have rules and directives that are clear and crisp. Even though diets typically fail in the end, part of the reason they are enticing is that they tell us what to do, which simplifies things by taking some of the decision-making out of our hands while paradoxically making us feel like we have more control over the situation.

People who are coming to intuitive eating from a history of dieting commonly and understandably assume that intuitive eating is just a different house built from the same framework of dieting, hence absolute language that implies a set of rules. In reality, intuitive eating has no rules, but rather guidelines and ideas for consideration. The difference is more than semantics, as people who attempt to pound intuitive eating into a rules-based framework end up warping it into the hunger-and-fullness diet, which both misses the point of the approach and makes incorporation more difficult.

With that in mind, I might suggest tweaking the writer’s question in order to remove the implication that his hunger has to reach a certain threshold for him to gain permission to eat and that he must stop when his fullness hits a particular level. He – and everybody else who follows an intuitive eating approach – always has unconditional permission to eat. Tearing down constructs that tell us when we can and cannot eat oftentimes feels scary, but it is essential in order to create the space necessary for us to make multifaceted eating decisions that are in our own best interests.

Instead of the question being how can the writer listen to his body so he can adhere to rules regarding when he can and cannot eat, perhaps a more helpful set of questions would include: How can he listen to his body so he can notice what different levels of hunger and fullness feel like and how different foods make him physically feel? How can he listen to his body in order to be more adept at distinguishing between times when he is eating for physical hunger versus some other factor, such as emotional or social reasons?

In that sense, I actually think the writer is more ahead of the game than he realizes, for he listed some of the external factors – time, quantity of food available, his partner’s own eating behaviors – that are hindering him from making food decisions from an internal standpoint. The next step on this front might be to explore the pros and cons of maintaining the status quo versus implementing change in order to determine the extent to which he wants to and is ready to create change.

Another avenue to explore is the writer’s statement that as a consequence of his eating behaviors, he rarely experiences hunger cues. If we are not hungry as we head into an eating experience, detecting subtle signs of fullness as they set in can be more difficult due to a lack of contrast. In other words, we cannot notice hunger signals subsiding if they were never there to begin with. If we grow accustomed to an absence of hunger cues, we might lose the ability to recognize the more subtle stages of hunger. Therefore, the writer might benefit from performing some experiments to intentionally let himself get hungry, to really notice what that feels like, and then consciously eat in response to it and see how the experience contrasts to when he eats in response to external cues.

Becoming an intuitive eater is a process. The journey never looks exactly the same for two people, as we are all so different and unique, but one commonality is that the road traveled is rarely direct. We discuss ideas, experiment, gather data that suggests areas of opportunity for further growth, and repeat the cycle until someone finds peace with food.

 

Humming and Beckoning

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Patients working with me on intuitive eating inevitably hear me use the terms humming and beckoning in the context of eating dynamics. Based on the feedback I receive, being able to differentiate between humming and beckoning is one of the most helpful skills for an aspiring intuitive eater to develop. So, what do these two terms mean, and why are they helpful? Let’s discuss.

Humming occurs when we are internally inspired to consume a food. Unprompted by anything external, we just feel that a particular food would hit the spot. Maybe you are sitting at your desk in the late afternoon, and as you begin to look ahead to dinner and consider what to purchase or make, you think to yourself, “Man, I could really go for [insert the object of your food craving].” Organically and unprompted, you just really want a particular food.

Beckoning happens when we are externally inspired to consume a food. We are not thinking about a given food, but circumstances unfold that result in us wanting it. Maybe brownies are not on your mind at all, perhaps you are not even hungry, but you walk by the break room, spy that someone brought in a pile of the homemade goodies, and suddenly you think, “Oh, hey brownies!” and take a couple back to your desk to munch on while you work.

Whether a food is humming or beckoning is not directly based upon a food’s nutrition profile, our ability to obtain the food, our beliefs about its appropriateness for the meal/snack at hand, our feelings about the food, or where it might fit on our good/bad food dichotomy (if applicable). Rather, humming and beckoning are directly based upon the source of our motivation – whether internal or external – for wanting a particular food.

Indirectly, however, our relationships with food can certainly influence our humming/beckoning dynamic. Going back to the brownie scenario I previously mentioned, someone who restricts their intake of sweets will likely experience a stronger pull towards the brownies than somebody who has a healthier relationship with such treats and knows they are free to have brownies at any time. The brownies might still beckon to both people, but the intensity of the sparkle differs, as might their responses.

Eating in response to humming has its upsides. From the standpoint of satisfaction, foods that we are humming for are more likely to hit the spot and leave us feeling content. In contrast, if we are humming for one food but eat something else for whatever reason, we might overconsume in an effort to make up for quality with quantity, or we might scrounge around going from food to food in search of satisfaction. Think of someone who really wants ice cream but gets frozen yogurt instead because they believe it to be healthier. They might overeat on the yogurt and perhaps eat another dessert or two afterwards, whereas if they had just had a little bit of ice cream in the first place, it would have hit the spot, and they could have gotten on with the rest of their day having found contentment in their eating experience.

Sometimes we do not give enough credit to our bodies, which are pretty good at directing us towards what we need. Think of how water tastes so much better and is that much more satisfying to drink when we are thirsty versus when we are already well hydrated. Someone with anemia might not know that red meat is high in iron; they just know that they could really go for a steak, as their body increases its perceived appeal of high-iron foods. Personally, I discovered that salted crackers and pretzels were particularly satisfying during and after marathons long before I understood that my body was trying to replenish its sodium and carbohydrate stores.

While eating in response to humming is typically a positive, beckoning is often viewed as a negative phenomenon, something to be resisted. However, I believe that beckoning gets a bad rap, and sometimes letting it guide our eating decisions is actually both sensible and helpful. Consider the following examples.

Rarity: My first job as a dietitian was a research position that had me flying all over the eastern United States examining food and eating behaviors in elementary school cafeterias. Every night, I went out for dinner at local restaurants. In Philadelphia, I ordered a steak and cheese. A few weeks later in Tennessee, I made sure to get barbecue. My last trip took me to Tampa, where I ate plenty of seafood. These were not cases of humming just so happening to coincide with popular regional cuisines. Rather, these foods beckoned to me because these locales were known for them, and I wanted to take advantage of my rare opportunities to experience authentic fare.

Similarly, you likely find yourself in situations on occasion in which you have an atypical opportunity to try a particular food. One of my patients, for example, told me that his co-worker makes amazing Chinese dumplings every year for their office holiday party. If he passed them up one December, he would have to wait another year for the opportunity to come around again, so of course he partakes in the dumplings whether or not he is humming for them the day of the party. Letting a rare chance slip away could leave one feel like they are not living life to its fullest

Deprivation: For someone still working to improve their relationship with food, especially if they have a history of dieting or other form of restriction, denying themselves a beckoning food can trigger feelings of deprivation that can have ramifications, such as subsequent overconsumption. Someone might decline the cake and ice cream at a birthday party and then rebel against their self-imposed restriction by consuming an entire pint of ice cream later in the day. In this example, the person would have been better served to remind themselves that they have unconditional permission to eat whatever and whenever they want and then celebrate with the other partygoers by having a little dessert.

Uncertainty: Sometimes our humming signals are just not that strong. We know we are hungry, but identifying the best fit proves a challenge. We might ask ourselves matching questions regarding what taste, color, temperature, or flavor food we feel like consuming, yet come up with limited criteria that still leave us feeling directionless and frustrated. In such cases, beckoning can be our friend by helping us to resolve the uncertainty and make a decision. For example, you might be gazing at a restaurant menu in frustration, unsure which entree to order, but then you glance at another patron’s meal, think to yourself, “That looks good,” and suddenly you have your answer.

Other times, not responding to beckoning might be the best move. The person who walks by the break room and spies the brownies might decide, “You know what, those brownies do look good, but I was not really feeling like having brownies; I am only interested in them because I saw them, and they are probably not going to hit the spot as they would if I were humming for them. Besides, I have unconditional permission, so I can make or buy brownies anytime I want. So, I am going to pass on them for today.” Five minutes later, they could be back at their desk and engrossed in their work, having totally forgotten about the brownies.

In my view, eating because of either humming or beckoning are both morally neutral actions, and there are no absolute right or wrong responses. However, understanding the dynamics behind our draw to a food can help us engage in whatever eating behavior we feel like is in our best interest at the given time.

Intuitive Eating and Infants

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It’s been a number of months since I last wrote for the newsletter (8.5 months, to be exact!). As most of you know, Jonah and I became parents last June to a wonderful baby girl named Lorelai. I’ll be honest, the first few months with Lorelai were a blur of diapers, bottles, and swaddles, but once she reached about six months old, things started to settle down a bit. Around this time, on the advice of her pediatrician, we started introducing solid foods. It has been such an eye-opening experience to watch her begin to navigate food, and it has given me a front row seat to what purely intuitive eating really looks like.

Of course, Lorelai was an intuitive eater from the day she was born. When she was hungry, she would cry and would eat until she was satiated. Some days she was seemingly ravenous, and other days she was not so hungry, but she steadily gained weight and thrived. Since she only had one source of food (first breastmilk and then formula), there was no real choice about what she was eating. That’s what happens when there is only one food on the menu! But introducing solid foods increased her options, and that’s when things got interesting.

Lorelai’s first solid food was baby rice meal mixed with formula. When we initially tried to feed it to her, she pursed her lips and seemed truly offended by the spoon. We didn’t want to force anything on her, so we waited before trying again, and eventually she allowed the spoon into her mouth. Her puzzled face spoke volumes as she could not fathom what was in her mouth, never mind how to eat it! She opened and closed her mouth and then proceeded to push the food out with her tongue, causing the food to land on her bib. She didn’t cry or seem upset, just genuinely perplexed about this new development. None of this food made it past her mouth. We were assured by our pediatrician that this was totally okay and normal, as the introduction of solids for the baby is mainly about teaching her food comes in forms other than just liquids. The baby learns to taste and manipulate the food in her mouth and may or may not swallow it. During this time, her formula continued to be her main source of fuel.

As the weeks went by, we continued to try introducing new solids, moving next to baby oats and then adding things like mashed banana and pureed pear. With each feeding, Lorelai became more and more interested in food and started not only to mouth and gum it, but swallow it, too. Her food preferences started emerging at this time as well. From the get-go, she was not a fan of white potato, which she made evident by promptly vomiting it up after a few reluctant bites. Similarly, she votes “no” on pureed peas. Pretty much all fruits are her favorite foods, especially pureed blackberries.

But even in this short time, some of her preferences have changed. When we first tried to give her avocado, she looked at us like we had three heads. She pursed her lips and pushed it away and was not having it at all. We wondered if maybe she could try feeding herself avocado, she might like it better. And that is exactly what happened! Instead of giving her mashed avocado and spoon-feeding it to her as we had done previously, we gave her avocado slices with the peel on so she could hold it herself. To our surprise, one day she picked up an avocado slice and joyfully started chewing on it. It is now one of her staples, and she loves it. The same thing happened when we introduced her to Bambas, crunchy peanut butter snacks that are very popular in Israel. At first, Lorelai was not at all interested in them, but at some point, she began to pick them up and hold them and put them in her mouth, and now she eats them every day and loves them.

Even with her ever-growing repertoire of foods, Lorelai has maintained her ability as an intuitive eater. If we present her with food, even if it’s one of her favorites, and she is not hungry, she won’t eat. And if she is hungry, she will eat until she is satiated and then stop eating, even if there are a few bites left. I have always spoken with my patients about how we are born intuitive eaters, and as we get older, we often lose that ability for numerous reasons (dieting, being told to clean our plate or that some foods are bad for us and aren’t allowed). Much of my work with these patients is around rediscovering their inner intuitive eater and getting back to the time when they explored and enjoyed their food and made choices based on whether they were hungry or not and whether they liked what they were eating. It has been such an amazing experience to watch Lorelai’s intuitive eating up close, and I truly hope she will maintain this ability throughout her lifetime. Of course, I know that I won’t be able to shield her completely from diet culture and its toxic messages around “good/bad” foods, weight, and appearance, but I hope to foster her intuitive eater and help her develop a joyful relationship with food and her body.

Dietetics Within the Health at Every Size (HAES) Framework

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“Just tell me what to eat”

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

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

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

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

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

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

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

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

He Said, She Said: Good for who?

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He Said

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

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

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

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

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

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

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

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

 

She Said

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

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

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

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

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

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

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

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.