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.

 

Walking While Jacketed

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The Needham police stopped me while I was out for a walk yesterday morning. Reportedly, someone had called them to express, umm, “concern” that I was pushing an empty stroller. But the stroller was not empty, as the officer quickly realized when I introduced him to our infant daughter.

Even if the stroller had been empty, that is not a crime. Maybe I was returning home from dropping my baby off at daycare, or on my way to pick her up from visiting with a family member. Perhaps I was going to use the stroller to transport groceries home from the supermarket.

After I asked the officer exactly what the caller said, he made mention of the heavy winter jacket I was wearing, suggesting that my wardrobe choice raised suspicion. Some people run warm, some people run cold like me, but neither one of these characteristics is illegal either.

Before I get to the elements of this incident with which I take issue, let me first state what my problems are not:

My problems are not with the police department, and I am glad they responded to the call. What if I had actually been up to no good and they declined to pursue a tip that could have prevented a crime?

My problems are not with the responding officer. He was respectful throughout our encounter, and while he was understandably guarded at the outset, he became super friendly once he saw our daughter.

My problems are not with somebody keeping an eye on the neighborhood. “See something, say something” is an important call to action. Even in a relatively safe town like Needham, crimes still do occur, and we have to look out for each other and help the police to protect us.

My first problem is that what constitutes suspicion needs to be set at a higher threshold than what was exhibited yesterday. All the caller saw was a guy, a stroller, and their own prejudices.

My second problem is that not everybody gets treated the same by first responders, so when somebody ponders calling the police, they have to consider not just what crimes their call might prevent, but also what crimes their call might cause. As a white guy, I can see a police officer approaching me and feel confident that whatever transpires during our imminent encounter, I am likely going to be treated fairly and that my safety is probably not in danger. If I had dark skin, I would be less optimistic. We do not have to watch the news for very long before we see examples of seemingly-benign calls to the police resulting in murders of minorities.

My third problem – and the reason I am writing about this in a nutrition blog – is that this incident is emblematic of a broader issue in our town: We judge each other for our looks. Some of my fellow Needhamites have given me a hard time for my appearance as far back as elementary school, when my chosen attire and hair style were out of step with the hip childrens’ fashions of the day. While I am not equating picking on a kid on the playground for his hair and clothes with calling the police on an adult for his jacket, I am saying that they exist on the same bullying continuum and that they are both symptomatic of an intolerance/phobia/disrespect of people who are different than oneself.

This latter point is what most frustrated and disappointed me about yesterday morning. All these years later, from the 1980s Broadmeadow playground to 2019 in my own neighborhood, the message is the same: Look different in this town at your own peril. Despite all of the changes that Needham has undergone over the past few decades, the pressure to conform remains fully intact.

Nobody should be surprised then that so many of our patients are working to overcome eating disorders, many of which – but certainly not all – were triggered by a desire to escape weight-based stigma, shaming, and bullying and to become a member of a more socially accepted group. No wonder then that some of our patients with restrictive disorders are reluctant to weight restore; after having a taste of thin privilege, surrendering it and returning to the crosshairs of stigma is a difficult proposition. Similarly, it is understandable that patients of all ages have a hard time giving up their fantasies of becoming thin, which is a necessary step in healing their disordered relationships with food.

A small fraction of our readers take umbrage at our occasional discussion of politics and societal issues, but most people seem to understand that if we are truly going to help our patients with their nutrition, we have to do more than address the nitty-gritty of food and eating behaviors. We have to advocate not just for greater tolerance of questionable fashion choices, but also for serious issues of equality. We have to fight for size acceptance.

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.

What’s the deal with that egg study?

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One of the most common sources of nutrition-related frustration that patients express to me is the apparent fickleness of nutrition advice. It feels as though headlines and sound bites demonize a food that only yesterday was deemed the food of the Gods, or vice versa, leaving exasperated and confused eaters at a loss.

Eggs became the latest example when a recent Northwestern University study was picked up by mainstream media and turned into “clickbaity” headlines, such as “Bad news for egg lovers,” “Eating Eggs and Cholesterol Linked to Heart Disease and Death Risk,” “Are eggs good or bad for you? New research rekindles the debate,” and “Northwestern study cracks dietary guidelines for eggs.”

Unfortunately, disconnects often exist between headlines – which, remember, are sometimes sensationalized and designed to generate clicks, views, and shares – and the research behind them. For example, the Northwestern study in question is not actually bad news for egg lovers. Far from it. Let’s take a look at the study.

The study relied on self-reported dietary data, which are terribly flawed. Sometimes during the course of our work, I may ask a patient to keep a food journal and return it to me for analysis. Despite patients’ best efforts to keep accurate journals, their sources of error are ultimately numerous. People misremember what they consumed, forget to report some of what they ate, provide vague information that I can easily misinterpret, and purposely falsify data for fear of judgment.

Close to a decade ago, I was working on a research study that in part required that I interview people about what they ate the preceding day. As I sit here right now, I could not tell you what I ate for dinner last night, and the subjects were no different. One of the gentlemen I interviewed got frustrated because I had to drill down to such a specific level of detail that I was asking him for the measurements of the piece of lettuce he put in his previous day’s sandwich; meanwhile, he could not even be sure that he had eaten a sandwich at all. Eventually, my research team made the decision to drop the dietary recall portion from our study because the data were just so poor. Similarly, how confident can we really be that subjects included in the Northwestern study accurately reported their egg consumption?

Even if we take the data at face value and assume them to be completely accurate, we must remember that this study only found associations between egg consumption and disease, which is not the same as establishing a causal relationship. One of the most common mistakes that people make is to assume that correlation implies causation, but such an assumption is premature at best and can turn out to be just plain wrong.

Just because two events tend to occur together does not mean that one causes the other. Consider what our friend and colleague, Ragen Chastain, famously wrote in 2017. “Imagine if I got together everyone who had survived a skydiving accident when their parachute didn’t open and started looking for things they have in common. Even if every single one of them wore a green shirt and had oatmeal for breakfast, I cannot say that wearing a green shirt and eating oatmeal will allow you to survive a skydiving accident, nor can I ethically start Ragen’s School of No Parachute Skydiving ‘free green shirt and oatmeal with every jump!'”

In other words, even if it is true that people who consumed more eggs had a greater incidence of cardiovascular incidents and death, we cannot say for sure that the eggs were responsible, just as we cannot say that blueberries reduced heart attack risk, because it could be that another factor – or combination of factors – common to people who consumed more eggs is responsible for their disease and death as opposed to the eggs themselves.

Observational studies like these are great for developing hypotheses to be explored in subsequent research, but their design prevents them from establishing causal relationships. Unfortunately, this incredibly important point is often glossed over or ignored entirely when a study is distilled to pop culture news articles and then further condensed into headlines.

Consequently, the news that we see leaves us with the impression that nutrition information and guidance are always changing like early springtime New England weather. Don’t like seeing your favorite food being vilified? Just wait until tomorrow when a new headline will sing its virtues.

In reality, nutrition science moves at a more glacial pace. One study generates hypotheses that subsequent studies investigate, followed by yet more research that looks at the given questions from different angles in an attempt to confirm or refute the original findings and gain a deeper understanding that policymakers eventually take into account when issuing dietary guidelines.

If someone’s current egg consumption is working for them, I see no compelling reason – based on what we know at this point – for changing it.

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.

Evelyn

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Some blogs take me longer to write than others. This one, I started four years ago, shortly after my grandmother, Evelyn, died suddenly of a stroke at 95 years old. Ravaged by Alzheimer’s, her memory had badly deteriorated, and she was residing in a senior living facility with a great staff who cared for her.

The latter point is at least the rumor because I do not know firsthand; I never actually visited her there. My grandmother and I had not seen each other in probably a couple of years when she passed. Although her memory problems were at first an annoyance to which we responded with humor – for example, my father would respond to her “How’s work?” questions with “Fine” rather than remind her that he was retired – her memory grew more concerning over time. First, she called my wife by the wrong name, then forgot her name entirely. My fear was that I would walk into her room and hear, “Who are you?” That would have been tough to take.

My grandmother was a complicated person. Everybody has challenges, some more than others, and she quite often met hers with twists of the truth. If you knew Evelyn well, then you know exactly what I mean. So the distance that divided us in recent years was both of my own making and her limitations.

Before that though, our relationship was solid. Although Evelyn was a reluctant mother who never truly embraced parenthood and the life changes that it requires, grandmotherhood was an entirely different story, and she was damn good at it. That included great-grandmotherhood. At a family gathering close to a decade ago, my niece and nephew were acting a bit rambunctiously and ignoring their parents’ directives to calm down. Their great-grandmother came over and said to the kids, “Let’s have a contest to see who can stay quietest the longest.” Right away, both children went silent. My brother turned to me, shocked. “I can’t believe that actually worked!”

My three favorite memories of my grandmother are as follows:

  1. When I was little – and I mean little, like nursery school or early elementary school little – she handed me a couple of dollars, as my grandparents often generously did when they visited. Not meaning it as a hint, but rather just stating a fact, I told her that I was just a couple more dollars shy of being able to buy a Dukes of Hazzard toy that I wanted. Right away, she reached into her pocket and gave me the money I needed. Thirty-something years later, that generous move has stuck with me.
  2. My brother and I occasionally had sleepovers at my grandparents’ condo. Typically, I stayed in one room with my grandmother while my brother shared a room with my grandfather. One evening, they switched things up, which did not go over well. Faced with the prospect of spending the night with my grandfather, I began crying. And then, apparently, I did not stop. I remember him, totally at a loss, calling for his wife, “Ev, he’s crying!” We switched back to the traditional configuration. In the morning, I woke up to find my grandmother looking at me and smiling, and I remember feeling very comfortable and safe.
  3. My grandparents visited us practically every Sunday except during the winters when they migrated to Florida. Each week, Evelyn arrived with food, including baked goods of various qualities. When I was a teenager, she caught wind of my liking peanut butter and jelly sandwiches. Every Sunday, for weeks and weeks on end, she showed up with PB&J she had made for me. Peanut butter and jelly is cool and all, but there is a limit. Afraid of offending her, I was wary of asking her to stop, yet I could see no end in sight. Anxiously, I dreaded waves of weekly sandwiches that could potentially keep coming until I went away to college. Still, I certainly appreciated the kindness behind her gesture, and that is what I remember most.

Food was a source of stress with my grandmother in other ways, too. As is typical of people who lived through the Great Depression, both she and my grandfather hated to waste food themselves, and it irked them when others did as well. Americans often forget that it was not too long ago in our history that food scarcity was a widespread and significant problem. Some of the original dietary guidelines from the 1940s emphasized the importance of butter and sugar because so many calorie-starved young men were failing their military physicals. Today, our area food banks and the lines outside food pantries are evidence that many of our neighbors still struggle to get enough sustenance.

People who have experienced food shortages oftentimes rebound by eating too much when food eventually becomes plentiful again. Virtually anybody who has ever dieted can relate to this, as food scarcity is often self-imposed. For Evelyn, these behaviors became so ingrained that decades later she still cleaned her plate and expressed dismay if others left food. “But there are starving people in China!” she would exclaim, as if someone overeating in Boston would make any difference whatsoever for a malnourished individual on the other side of the globe.

Eating with my grandparents was stressful, as I never liked being told to continue eating when I knew I was already full. To my parents’ credit, they stood up for me and overrode my grandparents’ commands. Still, the tension made family meals unpleasant because I felt pressure from both grandparents to eat past the point of comfortable fullness. They would comment if the portion I served myself seemed too small to them, and I certainly heard about it if I left food on my plate.

It took me years to figure out why I sometimes get anxious eating in restaurants, but through working on my own relationship with food, now I understand that it traces back to my grandparents. If a portion is set in front of me that I assess as more than I can comfortably eat, the anxiety sets in, the enjoyment of eating diminishes, and then the internal questioning begins. What fraction of the meal must I eat to feel confident that the waitstaff will not get mad at me? Can I entice my wife to eat some of it? Will anybody notice if I hide food in my napkin?

Rationally, I know the truth is that the waitstaff probably do not care how much I eat. So long as I pay for the food, how much of it I eat is irrelevant to them. If they do judge my consumption, it probably has more to do with disturbances in their own relationships with food or perhaps fear that I did not enjoy my meal.

Irrationally though, I continue to project my grandparents’ judgment onto the waitstaff. My work is ongoing, and I know that eventually I will overcome this, but in the meantime, I have figured out some workarounds that mitigate my anxiety while also honoring my body’s intuitive eating cues. For example, I may ask the waitstaff to pack up the remainder of my meal even if I know I will dispose of the leftovers as soon as we leave. One might argue that is a waste of packing materials, a valid point, but it is certainly a better choice than using my body as a garbage disposal.

Sometimes, I challenge myself. If I feel particularly courageous, I will just leave a heap of food on my plate, ask the waitstaff to take it away, and see how they react. In literally every single case, the waitstaff have never made a comment about the amount that I have left. Seeing the juxtaposition between my fears and reality has helped significantly, but the process continues.

Few of you care about my grandmother and my own food woes, a reality to which I take no offense, but all of this is meant to illustrate that the work we do in my office is typically deeper than people expect. In order to create meaningful change, we often have to look beyond calories and grams and instead focus on how people make decisions about what, when, and how much to eat. Doing so may involve examining the historical influences that shaped one’s current eating behaviors, which in turn paves the way for moving into the future with a healthier relationship with food.

The Natural Purple Pill?

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At this year’s Cardiometabolic Health Congress, a cardiologist I will call “Dr. Q” began his nutrition presentation with a factoid: 90% of cardiologists reported zero or minimal nutrition education, yet 95% of them felt it was their personal responsibility to discuss it. Meanwhile, 61% of the public thinks that doctors are “very credible” sources of nutrition information.

In other words, we have doctors who do not know what they are talking about talking about it anyway, and patients are listening and trusting them because they are doctors.

He called blueberries “the natural purple pill” and cited research showing that 93,600 women who were studied over 18 years and who consumed three servings of blueberries per week throughout the study had a 34% reduced risk of a myocardial infarction. He then flashed a slide listing the dozens of known chemical compounds in blueberries, asked how we know which nutrient or combination of nutrients is responsible for the benefits, and answered his own question with, “I don’t think any of that really matters,” intimating that the bottom line is that blueberries offer health benefits.

But the underlying mechanism absolutely does matter. He assumed a causal relationship between at least one of the chemical compounds and reduced risk of heart attack, but the relationship between blueberry intake and heart attack risk could also be correlation. For example, the real factor at play might not be some minute compound, but rather money.

Relative to other fruits, blueberries are incredibly expensive. According to data I obtained from Peapod.com, blueberries cost $0.44-$0.64/oz. (depending on the size of the container purchased), which exceeds apples, grapes, melons, strawberries, and all other fruits I examined except for pomegranate seeds ($0.63/oz.) and raspberries ($0.56/oz.)

Could it be that the women in the study who could afford to eat blueberries three times a week also had other financial advantages that enabled them to take better care of themselves, such as the ability to absorb higher insurance costs for office visits and testing, health club memberships, time off from work or no work at all, massages, and psychotherapy?

On the flip side, you know who is probably not splurging on blueberries or able to engage so extensively in taking care of their health? Those working multiple jobs just to get by, those living paycheck to paycheck, those suffering from food scarcity, those relying upon the Thrifty Food Plan, and those who need to make $3.33 stretch enough to buy multiple items to feed their entire family instead of blowing it on a small container of “purple pills.”

“Whether measured by income, formal education, or job status, there is a socioeconomic gradient to health,” Bacon and Aphramor write in Body Respect. “And the greater the inequality in society, the steeper the gradient. The United States has the greatest inequality of all wealthy nations – and the greatest health disparities.”

This is what I was getting at last year when I wrote about nutrition and politics. We talk about the concept of intersectionality and how various layers of oppression aggregate. The further one’s identity lies from that of the pinnacle of privilege – a thin, white, heterosexual, educated, wealthy, American-born, Christian male – the more the individual is subject to oppression.

It might not just be that one’s economic situation makes regularly consuming blueberries unrealistic and limits their access to health care, but that in addition to fretting about cash flow, that person might also have to worry about suffering a hate crime or having their rights stripped away. Even if someone does not fall victim to such misfortune, remember that stress itself is associated with cardiovascular disease, so the very threat itself is problematic.

Assuming that the reduced risk of heart attack was due to a few weekly handfuls of berries without considering the greater context is ridiculous and exemplifies the problems inherent in viewing nutrition solely as a hard science. Anybody who has extensively studied the field should know to consider social, cultural, and other factors, which makes me wonder: When Dr. Q told us that 90% of cardiologists reported zero or minimal nutrition education and yet 95% of them felt it was their personal responsibility to discuss it, was he describing himself?

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.

Soolman Nutrition is moving!

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Most of you know by now that our practice is moving soon, but now we finally have the details to share with you.

Our last day practicing at our current location in Wellesley is Friday, August 24th. We will then close for a week while we move the practice three miles down the road to Needham, where we will reopen on Tuesday, September 4th.

In order to avoid confusion regarding where appointments are happening this week, we are purposely refraining from updating the address and telephone number on soolmannutrition.com until we have closed the Wellesley location. Please check back during the last week of August for these pieces of information.

The new office will have a familiar feel to it, as the office layout, size, and colors are strikingly similar to those of our Wellesley location, but you will also notice some improvements:

(1) The Needham location offers plenty of free on-street parking. No more fighting for a parking space, feeding the meter, and racing the parking enforcement officers to your car after your appointment.

(2) Situated in a quiet residential neighborhood, the Needham location offers greater privacy for those who prefer discretion while going to and from their appointments.

(3) Unlike the Wellesley office, our Needham location is fully handicap accessible, including a wheelchair lift and ADA-compliant restroom, so everybody has equal access to the care they deserve regardless of physical ability.

A less significant piece of news, but one still worth mentioning, is that we will be shortening our business name when we move the practice to Needham. Wellness is admittedly a somewhat vague term and, honestly, I do not even remember what I was getting at when I named the practice all those years ago. More than anything, its inclusion leaves people scratching their heads as to what we do. We are the Soolmans, and we help people with their nutrition, so Soolman Nutrition LLC is all we need.