The “T” Word

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“You run into that more than I do. All of my patients are already in therapy.”

That is how Joanne responded when I suggested that she write a feature about the challenge of helping resistant patients in need of therapy to agree to go. Apparently, the responsibility of writing about the topic then falls on me, and appropriately so, I suppose, for I do run into this issue quite often on my side of our practice.

Joanne rarely runs into this dilemma because she focuses exclusively on eating disorders, and by the time a patient makes their way to her, the importance of a complete treatment team – a dietitian, a physician, and yes, a therapist – has usually been explained and emphasized to them at some point already.

In contrast, while eating disorders are similarly my area of specialization, I also help people with other conditions, such as high cholesterol and hypertension. As such, I tend to attract patients who view – or want to view – their challenges as superficial food issues even if it quickly becomes apparent to me that something deeper is at play.

That brings us to a critical juncture in our work and often a difficult conversation. How do we emphasize the importance of therapy while remaining sensitive to the reality that we live in a society that stigmatizes mental health issues?

Well, we do just that. We talk about the upsides of therapy as well as the patient’s thoughts, questions, and concerns, including any hesitations they might have. Oftentimes we also talk about the stigma because I think it is important to bring out into the open the reality that a therapy referral comes with a connotation that would not arise if I were suggesting someone meet with pretty much any other kind of specialist.

Sometimes patients are hesitant to disclose their true reasons for not wanting to go to therapy, or maybe they have trouble putting their fingers on what their reasons are, but they know they do not want to go. “It is not worth the time,” “I do not hate myself,” and “I have friends I can talk to” are some of the superficial reasons patients have told me. Time, trust, and continued conversation are sometimes necessary for us to get to the point of having a candid discussion about whatever their hesitations really are.

A common sentiment I hear is, “I think I want to start with just a dietitian.” Earlier in my career, I had a peer supervision leader who refused to work with a patient with an eating disorder unless they were also in therapy, a policy that I then adopted. Eating disorders are mental health issues that play out through eating behaviors, so while they affect nutrition, they are not directly nutrition issues. The dietitian’s roles are to provide nutrition support (if applicable) and to help the patient form a new and healthier relationship with food as the disorder recedes. However, because eating disorders are mental health issues, the bulk of the recovery does not happen with a dietitian, but rather with a therapist. Without this key member of the treatment team, the patient’s chances of recovery drop so dramatically that some dietitians, including my peer supervision leader, feel it is unethical to work with someone who refuses therapy.

In the last few years, as a result of conversations I have had with other colleagues, I have reversed course. The rationale is that if I terminate my work with a patient who refuses therapy, then they are left with nobody to help them, but if I continue working with them, then at least they have me in the meantime, and, hopefully, they will become more open to the idea of therapy as time goes on.

As dietitians continue to debate this issue, my own ambivalence oscillates from one side to the other and back again, and I have no idea what my policies will be in this regard down the road. What I do know, and what dietitians who specialize in treating eating disorders agree on, is that therapy is essential for recovery.

Therapy can also be immensely helpful for some patients without eating disorders, too. One of the most interesting aspects of nutrition work – but also one of its greatest challenges – is the wide array of factors that influence the decisions we make regarding what, when, and how much to eat. Many examples, such as low self-esteem or a poor relationship with a close family member, can significantly affect eating behaviors, yet are largely beyond my expertise to treat alone. The boundary of my scope of practice bleeds into that of mental health professionals, who can effectively address these deeper issues and free people up to form healthier relationships with food.

“Food Addiction”

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As we make our way into the fall season, it is inevitable that the topic of sweets at Halloween starts coming up with our patients. Many of our patients have a love/hate relationship with Halloween, starting when they were kids. Most remember being restricted around candy by their parents and have vivid memories of having limited access to their haul or sometimes no access at all. One recalls when her parents actually paid her $50 in exchange for her giving up all of the candy she had gathered. Another remembers sneaking her candy bag into her bedroom and eating chocolate in her closet so her mom wouldn’t see. Most of these individuals grew up feeling like they were addicted to sugar or food in general and that they could not be trusted to be around these foods.

Diet culture would have us believe that sugar/food addiction is a real phenomenon and that it is the reason for our “obesity epidemic.” Countless diet gurus and programs are dedicated to helping their clients “break the sugar habit” and cure themselves of their addiction to food. The food addiction model claims that certain foods light up the pleasure centers of the brain, which means that these foods elicit a pleasure response similar to that of drugs and alcohol. Other things that light up the pleasure centers of our brain: hugging a loved one, laughing at a funny joke, breastfeeding and/or holding your baby, listening to music you enjoy, and falling in love.

The only reason the food addiction model has been posited is because of fatphobia. Are we concerned with laughing addiction or hugging addiction? No. It’s only because people who feel that they are addicted to food are likely engaging in a lot of physical and/or mental restriction to try and control their weight. If being or becoming fat was not vilified like it is in our diet culture, people would not be restricting themselves and thereby would not feel out of control with these foods. Restriction begets bingeing.

Most studies that have been done on food addiction have been performed on mice. Interestingly, most of these studies found that the mice that were restricted from the highly palatable rewards foods and were presented these rewards at intermittent intervals were much more likely to overeat at these times. Similarly, other studies have shown that when humans are deprived of certain highly palatable foods (foods high in sugar, salt and fat), they have a heightened brain response to those foods when they see them. This means that those “forbidden” foods become much more appealing and attractive to the restrained eater than the non-restrained eater. None of the food addiction research currently controls for deprivation, meaning that they don’t measure if the subjects are currently dieting or have dieted in the past before conducting their studies.

The abstinence model of substance addiction is considered the gold standard right now. But unlike drugs and alcohol, one cannot simply abstain from food. There is a biological reason why food lights up the reward pathways in our brain – survival instinct! This causes us to seek out food when our bodies need it, which is necessary in order for our species to survive. On the other hand, we could live our lives without consuming any recreational drugs or alcohol and survive just fine.

All of this is to say that many people feel like they are addicted to food. What I would argue is that the behavior of eating might feel like an addictive or compulsive one, but that food in and of itself is not an addictive substance. So what should we do about kids and candy? My advice is to make candy (and other highly palatable foods) available on a regular basis in your home – add them to meals (i.e., have them be part of the actual meal), let them be the afternoon snack here and there. And don’t refer to these foods as “treats” or “junk” as this immediately makes them that much more appealing and also much more likely that your kids will sneak and overeat these foods when they are available. By including these foods regularly, they will lose their “shine,” and when holidays like Halloween or Christmas or Easter roll around, the magnetic pull to these foods will be markedly diminished.

Questionable Measures

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Last month, one of my friends told me that his health insurance, Tufts Health Plan, offers Good Measures, a nutrition and exercise tracking website, for free to members like him. When I told him I had never heard of the site, he gave me his login information so I could check it out.

This piece you are reading is by no means a thorough critique of Good Measures, nor do I think a comprehensive evaluation is even necessary, for I have enough concerns from my limited exploration to know that I would not recommend this site to patients.

Having said that, to be fair, Good Measures does have some nice features. My friend, who is a software programmer and artist, was impressed by the site’s visual appeal and how user-friendly it is to navigate and input data. One feature that quickly caught my attention is that if it detects that a user’s intake of a particular nutrient is low, it will go through the person’s food logs and highlight the foods with high concentrations of the nutrient in question in order to show the user that they can increase their intake simply by consuming more of these foods they already eat. Good Measures also presents some new foods for the user’s consideration, which can help to inspire ideas.

My concerns about the website are less to do with its design or mechanics and more about the problematic messages it teaches about nutrition. Even though I do like how Good Measures helps to generate ideas for consuming more of a given nutrient, users are misled into believing that underconsumption is definitively a problem when in fact it might not be at all.

Someone can consume less of a particular nutrient than their estimated needs would call for and often be just fine, but Good Measures teaches quite the opposite by labeling such shortfalls as “under and it matters.” Implying that someone has to hit their target intakes every single day or risk malnutrition creates unnecessary stress and is ultimately misleading because that simply is not how our bodies work.

Deficiencies, which can often be detected through blood analyses, can develop over time if intake of a particular nutrient is chronically low, but they do not suddenly appear after a single day, or even a few days, of consuming below one’s estimated needs.

Part of having a healthy relationship with food is being flexible and varied in our eating. We will be hungrier and eat more on some days than others. Our intake of a particular nutrient could be quite high one day and quite low the next, and that is perfectly fine. In the big picture, our bodies get what they need even if each day is a bit different.

Getting down into the nitty-gritty, another problem I have with how Good Measures addresses issues of nutrient deficiencies and excesses is that it does not take absorption into account. Commonly, we think of putting food “in” our bodies when we eat it, but technically speaking, the food is not actually inside our systems until it has been digested and absorbed through the lining of our gastrointestinal tract.

Various factors influence the fraction of consumed nutrients that make their way into our bodies. Some of these factors are unique to us, such as our genetics and gut microbial populations, but examples of others include food sources and combinations. Good Measures could not possibly take the former into account, and it seems to make no attempt to factor in the latter either.

Consider iron and its two forms, heme and non-heme. Our bodies are quite poor at absorbing iron, but heme iron, which is found in animal flesh, is better absorbed than non-heme iron, which comes from plants. If I eat a piece of steak or a pile of beans with equal iron contents, my body will absorb more iron from the meat than from the legumes. Poor absorption of non-heme iron is why vegetarians are often advised to consume more iron than omnivores, but Good Measures does not seem to account for this. Taking in an iron-containing food with a source of vitamin C, such as a glass of orange juice or some red pepper slices, will improve iron absorption, but Good Measures does not seem to factor in this physiology either.

That such important nuance was overlooked does not surprise me, as my impression is that this website was purposely designed to be overly simplistic. Consider the Good Measures Index (GMI), the definition of which is, well, I will let the website’s help directory explain it.

In my opinion, one of the most significant problems in how our culture views food and nutrition is that we oversimplify and overgeneralize multifaceted issues to the point where our distillations teeter on the border of doing more harm than good, and sometimes they cross right over that line. Given how complex our bodies and our relationships with food are, the notion that our eating can be boiled down into a numeric value strikes me as dubious at best. 

Beyond that, while the GMI seems designed to suggest that there are no good/bad foods, its impact is quite the opposite. Using my friend’s Good Measures profile as a testing ground and various real-life binge incidents that patients have reported to me, I experimented to see how an evening of overconsumption would affect my friend’s GMI. The most severe of the three binge episodes that I tested was enough to plummet his day’s GMI from 94 all the way to zero, which is ridiculous on multiple fronts.

The binge foods that I used in the example, even if they were consumed in excess, provided an abundance of nutrients that the body would utilize to function. To suggest that a binge can negate everything that came before it is nonsense. Reducing the day’s GMI to zero tells the user that positive eating experiences that may have occurred earlier in the day can be undone, which is false and hearkens back to the problematic calories-in vs. calories-out model in which someone’s exercise bout can be viewed as cancelled out if they take in “too many” calories afterwards.

The GMI’s 0-100 scale is similar enough to academic grading to suggest that 100 is perfection, a target for which to strive, and that a score less than that is due to errors, like wrong answers on an exam. In reality, a 100 GMI could indicate that someone is too rigid and might be struggling with orthorexia. Even my friend, whose relationship with food strikes me as quite healthy, felt like his 94 GMI must indicate that he is doing something wrong and wondered out loud if he should be striving for 100. In my practice, I have seen so many eating disorders that were sparked when a high achiever with perfectionist tendencies applied these traits to their eating, and I can easily imagine the GMI furthering this problem.

Another area where Good Measures takes a complex topic and dumbs it down to useless numbers is weight control. Pursuing weight loss is dangerous and problematic for the reasons we discuss here, yet Good Measures acts as if it is just a matter of elementary school arithmetic. Input your age, gender, height, current weight, activity level, and desired weight, and it outputs “your personalized daily calorie goal.”

Earlier in my career, I also used algorithms like theirs to advise people on weight loss. In the long run, they do not work. The calories-in vs. calories-out energy balance paradigm is an oversimplification of the factors that influence weight regulation, which is mostly out of our control.

Consider atypical anorexia nervosa, a condition with all of the restrictive features of anorexia, but the patient is not medically “underweight” despite their severe malnutrition. In other words, atypical anorexia nervosa is, as some of our colleagues say, anorexia nervosa without the weight stigma. Good Measures and other nutrition and fitness trackers can present all the “success stories” they want, but the truth remains that sometimes – oftentimes – our bodies just do not lose weight in accordance with what simple math would predict.

At the other end of the spectrum, weight gain is no guarantee either despite Good Measures also suggesting that putting on mass is just a matter of taking in enough calories. One of my best friends is very thin and wanted to put on weight for aesthetic reasons. He has a PhD in physics, understands energy balance as well as anybody out there, and explained to me that all he has to do to gain weight is take in more calories than he expends. The human body is more complex than that, I cautioned him, but he insisted. Over the ensuing weeks, he increased his caloric intake, logged everything he ate, and tracked his weight on an Excel spreadsheet. One day, he emailed me his spreadsheet and a message saying, “WTF?” While he had gained a small amount of weight, his spreadsheet showed that his weight had leveled off and would no longer budge no matter how many calories he ate. Changing our weight in either direction is just not nearly as straightforward as Good Measures makes it seem.

Tufts Health Plan members who use Good Measures also receive at least one free telephone consult with a registered dietitian, so in fairness, it is possible that the professional on the other end of the line might help to clarify some of the website’s limitations and put the data into better context. However, the soonest appointment my friend could get for his initial consult will not take place until nearly two months after he started using Good Measures. If that is a typical wait time, that means users have approximately eight weeks to misinterpret and internalize whatever they glean from the site.

For nearly two months, people who have an active eating disorder, a history of one, or are at elevated risk for such a disorder are using a triggering tool that can start a downward spiral without first being informed of the risks. According to one estimate, 14.3% of males and 19.7% of females will experience an eating disorder by the age of 40, which loosely translates to one in six individuals overall. Given such high prevalence, Tufts Health Plan is negligent in offering Good Measures to its members without guarding against the harm it does to this segment of the population.

Despite having some nice features and an aesthetically pleasing design, Good Measures has fundamental issues that prevent me from recommending it to patients.

 

Coming Out

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I am officially coming out as fat today. I’ve been thinking about doing this for a while now. This concept might seem laughable to some of you. How can someone come out as something that everyone can plainly see? Take one look at me and my size and there is no question that I am fat, but up until fairly recently, I had eschewed the title of “fat,” something that I never wanted to claim to be.

I would describe myself with euphemisms: chubby, chunky, curvy, plus size. I would try to shrink myself in public, taking up as little space as possible lest someone feel like my body imposed on them. I would keep my gaze down as I passed strangers on the street, a way of showing my own shame and embarrassment for my body. I would dress in loose, baggy clothes so no one would be forced to see my belly rolls. If I went to the beach, I would be sure to wear a cover-up the entire time unless I decided to be brave and go for a swim. Then I would sprint into the water so that bystanders would not need to be assailed by the vision of a fat woman in a bathing suit.

All of this was an attempt not to take up space in the world, to show that I, as a fat person, was aware of my horrible shortcomings and was not okay with being in this body. The world that we live in confirmed these feelings often. Microaggressions would come in the form of friends discussing another friend’s weight gain or loss, family members commenting on what I was or was not eating, and doctors suggesting changing my diet without asking me what my diet looked like in the first place.

Like any “good fatty,” from a young age I would engage in different weight loss attempts to try to shrink myself and be “healthy.” My first earnest weight loss attempt was in my senior year of high school. I had made up my mind that I would finally lose the weight that had plagued me throughout my childhood and adolescence and be thin by the time I started college in the fall. Then I could start my new adult life in a socially acceptable body and everything would be perfect. I dutifully dieted, restricting all the foods that I loved, instead living on fat-free cottage cheese, vegetables, and sadness.

My body began to shrink and everyone noticed. I got compliments, invitations to parties, acceptance. My doctor was so impressed that he told me to “keep going” and “get skinny.” Meanwhile, I had lost my period, become completely obsessed with eating as little as possible, and was a grumpy, exhausted mess. At my worst, I was exercising twice a day to try to break the plateau. I was downing sugar-free candies to prevent myself from snacking between meals. (P.S. Fun fact about those candies: They are wicked laxatives!) I would loathe going out to eat with my friends and family, as I would be faced with all the foods I no longer allowed myself to have. Food and weight were all that I could think about.

When I went off to college in the fall, the wheels fell off the proverbial wagon, and I gained back all the weight I had lost and then some. The weight loss/gain cycle continued throughout college and into my 20s as I tried diet after diet, thinking that this time it will stick. But inevitably, the weight would creep back up, and I would feel humiliated and ashamed.

Little did I know then that my experience was not unique. In an analysis of 31 long-term diet studies, researchers concluded that while individuals can expect to initially lose 5% to 10% of their weight regardless of which diet or “lifestyle change” they choose, the weight inevitably comes back, with at least one-third to two-thirds of people regaining even more weight than they had lost in the first place. Another study that looked at the effectiveness of traditional dietary and exercise interventions for weight loss determined that while there is not much long-term follow-up data in the effectiveness of these interventions, “the data that do exist suggest almost complete relapse after 3-5 years.” And those 3-5% of dieters who do manage to keep the weight off for more than 5 years spend all of their time and energy trying to stay that way, often by using disordered eating and exercise behaviors.

I remember reading an article in the New York Times about nine years ago that focused on the National Weight Control Registry (WCR), a research study that follows individuals who have lost at least 30 pounds and have kept it off for at least a year. The article featured a husband and wife who had lost over one hundred pounds each and had been on the WCR for five years. In order to maintain their weight, the couple engaged in a rigid regimen of diet and exercise. Both of them not only exercised for a minimum of two hours per day, they also weighed and measured every morsel of food they ate, logging it into a food diary. They severely limited not only their calories, but the types of calories they were eating (e.g., low carb, no desserts). The wife herself said, “It’s pretty easy to get angry with the amount of work and dedication it takes to keep this weight off,” but the alternative (i.e., gaining the weight back) was not an acceptable outcome for her.

Part of the reason I made the decision to become a registered dietitian was the hope that I could finally crack the code of weight loss. I figured, well, if I learn about all the aspects of nutrition, I will be able to lose weight, keep it off, and help others to do so, too. Before entering the nutrition program, I had dieted down to a lower weight and thus was obsessively thinking about food and my body. Interestingly, by the time I had completed my dietetic program, internship, and Master of Science in nutrition, I had again gained back all of the weight I had lost. Of course, I was quite unhappy with this development but still believed that I could figure out my weight dilemma eventually.

My first dietetic job was at an eating disorder center where I was a registered dietitian working with residential patients. It was around this time that things started to shift slightly for me. I saw how the patients were treated differently based on their body size. For instance, those patients in larger bodies, regardless if they had been admitted for restriction or not, were put on “weight maintenance” meal plans to prevent them from becoming “too fat,” while those patients in smaller bodies were encouraged to eat more to restore their weights to a “healthy weight.”

Basically, we were prescribing behaviors to one group of patients (restriction for those in larger bodies) that were considered disordered in the other group of patients. This double standard did not sit well with me, but I adhered to the guidelines at the center. At the same time, I was still fixated on shrinking my own body, terribly self-conscious of being a fat dietitian in a field known for a very specific type of person: white, female, thin. I thought to myself, “How will any of these patients take me seriously when they see my body?” I dieted once again during this period of time, and with my own wedding day approaching, I got even more obsessed about the number on the scale.

It wasn’t until after the wedding (and subsequent weight regain) that I finally had enough. This wasn’t working for me anymore, and it wasn’t for lack of trying. I had hit diet rock bottom and knew there had to be a better way. So when I learned of Health at Every Size® (HAES) and Intuitive Eating (IE) at a talk given by a colleague, I was so ready to hear the message that there was a way to live a happier and healthier life, a life where food is not the focus and where I could be free of the chains of dieting.

I delved into all of the HAES, body positive, and intuitive eating material I could find online and in various books. I attended workshops and lectures and even spent three weeks at a HAES/IE retreat. I started listening to podcasts, connecting with other HAES and IE practitioners, and before I knew it, my mindset had shifted significantly. HAES and IE spoke to me like no other paradigms or approaches, and once I learned that they are also both backed by scientific research, I was a convert.

During this time, of course I gained some weight after years of losing and gaining (in addition to having a baby), with my body finally landing in the “obese” range, at least for now. It is difficult to be in a larger body for many reasons. Doctor appointments have become more fraught as I brace myself for the weight lecture. Luckily I was able to find a weight-neutral doctor who knows not to talk to me about weight loss, but if I ever need to see a specialist, I know that inevitably my weight will come into the discussion.

Being in a larger body makes it harder to shop for clothes, fit in some spaces, and feel “normal” amongst my mostly slim friends and family. I never had to think before, “Will I fit in this seat?” But now these are things I need to consider. Being a “small-mid fat,” I want to acknowledge that I have much more privilege than those who identify as “large-fat,” “super-fat,” or “infinifat.” The hatred, mistreatment, and oftentimes abuse these individuals deal with on a daily basis make me simultaneously so angry and so sad.

Our diet-obsessed, fatphobic culture makes sure to remind me and other fat people that we are lazy, gross, sloppy gluttons who could be thin if we just tried hard enough and put down the bonbons. The overwhelming majority of people believe that weight is controllable and that if fat people just ate less and exercised more, they could be thin. Most people also believe that the health conditions that are often associated with larger body sizes (such as heart disease and diabetes) are directly caused by weight, even though there are thin people who develop these conditions, too.

While obviously what we eat and how much we move can affect our health, they are a very small part of the picture of overall health and wellness. Access to healthcare, socioeconomic status, oppression, and weight stigma have even greater impacts on our health than just diet and exercise. And just because someone does all of the “right” and “healthy” things does not guarantee that they will never become ill. Society would have us believe that the pursuit of health is a moral imperative and totally within our reach if we just try hard enough. But in the wise words of fat activist Ragen Chastain, “health is not an obligation, a barometer of worthiness, completely within our control, or guaranteed.”

Otherwise open-minded, liberal people who believe in equality and respect for those of different races, ethnicities, sexual orientations, religions, abilities, and gender identities do not consider body size diversity as something that also needs to be respected and protected. This world is not built for larger people, and existing in it can be torturous at times.

In addition to all of this, I still have a great deal of internalized fatphobia that I am constantly trying to counteract with body acceptance. I have had to come to terms that I will never likely be in a smaller body and that this is not the end of the world. At the same time, nearly everyone in my life lives and breathes the same diet culture air we live in, so it’s rare that I am not faced with some fatphobia, diet talk, or weight stigma. It’s like I’m swimming against the current of diet culture nearly 24-7, and sometimes I just want to give up and go with the flow or jump out of the water entirely. But knowing what I know about the lies of diet culture and how miserable my life was when I pursued thinness, I can’t go back.

So I am coming out as fat today to reclaim this word that has been used to taunt me and millions of other people but should honestly be just a neutral descriptor. I am a fat, fair-skinned, red-headed registered dietitian, wife, daughter, sister, friend, and mother. I am all of these things. And I am no longer going to stay in the body shame closet.

Privilege and Cowardice: A Chronology

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“You should have hit her. She’s black.”

It is 1989, and I am a sixth grader struggling to adjust to life at Pollard Middle School. We are in music class. Instead of practicing their piano parts, two boys are sexually assaulting one of our classmates, laughing as they repeatedly grab her breasts and pinch her buttocks despite her best efforts to swat their hands away.

When the brown-skinned girl sees me looking at her, she recoils and asks me if I am going to touch her, too. No, I would never, that is not at all who I am. But she does not know that. The fear on her face suggests that despite her young age, she has already learned to see every boy as a potential assailant. I do nothing. Neither does the music teacher.

Two grades later, I am walking through the science department hallway after school has let out for the day. The corridor is mostly empty, just me, a younger girl, and the two aforementioned boys. One of the latter flinch tests the girl, acting like he is going to punch her before stopping his fist just before her face. She remains silent and does not react. As they walk away, one boy says to the other, “You should have hit her. She’s black.” Afraid they might come after me, I say nothing. I do nothing. I tell no one.

It is November 2015, I am reluctantly attending my high school reunion, and I spot him, the boy – now a graying man on the early fringes of middle age – who spoke those words in the science department hallway. As soon as I see him, I think of these two incidents and wonder how many women and minorities he has harassed, bullied, intimidated, and assaulted over the last few decades in part because I did nothing to stop him.

 

Kicked

It is early spring in 1995, and my time at Needham High School is nearing an end. The best player on our tennis team is a black student who buses between his inner city home and our suburban school as part of the METCO program.

The time he loses every morning and afternoon sitting on a bus is time that I and many of my suburban-dwelling peers can use to study, do homework, seek tutoring or extra help from teachers, participate in extracurricular activities, or even just relax or sleep, all of which help directly or indirectly with our academics and college applications. We have a leg up on him based on proximity alone.

Not only is my teammate a great player, but he is also a super nice young man who goes out of his way to help us with our own games, including teaching me how to hit a kick serve. Meanwhile, I am stuck in tennis purgatory, sandwiched between a varsity roster filled with players better than me and our coach’s policy against allowing seniors on junior varsity. Coach explains to me that after three seasons together, he feels too bad to cut me, but that I should cut myself because I am not going to play. I refuse to do so and remain on the team solely as a practice hitting partner.

My personal and familial responsibilities enable me to spend every afternoon out on the courts, but my teammate has other obligations. He misses some practices, and coach tells him that if it happens again, he is gone. Then he misses another day because he has to give his brother a ride. Coach kicks him off the team, citing a lack of commitment. He cannot be in two places at once. What is he supposed to do? Yet none of his now ex-teammates come to his defense, at least, not to my knowledge.

As a result of his expulsion from the team, I get promoted to the varsity lineup and have an unexpectedly great season – thanks in part to my new kick serve – that springboards me to playing for my college.

It is my senior year at Tufts University, and not only do I get to tell potential employers that I am a collegiate athlete, thus implying that I possess a disciplined work ethic and an ability to function as part of a team, but I can add that I have been named a co-captain, suggesting that I have leadership qualities and the respect of my peers. Can my ex-teammate from high school list either of these accolades on his resume?

 

Being Followed

It is the summer of 1995, and I am a recent high school graduate working my first “real” job at Thunder Sporting Goods in Wellesley, the town in which gun-drawn police forced black Celtics player Dee Brown from his car and ordered him to lie on the ground in a case of mistaken identity five years earlier. Brown, who was originally from Florida, went on to say, “When you think of towns up North and you think of racism, you think of Boston.”

My duties primarily entail stringing tennis racquets and selling running shoes, but on this particular day, my manager gives me a different task. A neighboring retail store down the block called him to report that a black person had just been in their store and was apparently headed in our direction. My manager tells me to follow them around the store to make sure they do not steal anything.

His racist directive shocks me, yet I am intimidated by my boss, my first one ever, so I plan to keep myself busy with tasks in the same general vicinity as the shopper, but no way am I going to blatantly follow them around the store. Not a great plan, but in my 18-year-old brain, it feels like a compromise of sorts. As it turns out, the person takes their business elsewhere and never enters our store.

 

The “Bloody Shirt” Incident

It is 1996, I am a college freshman, and I agree to help a friend paint the set for her drama production. Afraid of getting paint on my nice sneakers, I wear my running shoes. It is late at night by the time I leave the scene shop, and since I have my running shoes on anyway, I decide to save some time and jog back to my dorm.

A policeman working a construction detail yells at me to stop. He sees red on my shirt and thinks I was involved in the fight he heard about over his radio. It is just paint, I tell him. Without getting close enough to me to verify my claim, he takes me at my word, and I continue running into the night. Now I have a somewhat amusing story to tell friends about the time a policeman briefly mistook me for a violent perpetrator. I am white.

 

Daewoo(d)

It is June 1999, and I am a recent college graduate. My girlfriend and I land in Las Vegas with plans to rent a car and drive to Phoenix and then San Diego for a short vacation before I enter the working world next month. The rental agency gives us the choice between two vehicles: a car to which they cannot find the key or a sketchy Daewoo without a license plate.

Somewhere in the Arizona desert, we get pulled over for speeding and driving a car without a license plate. Both policemen are friendly, and as one of them does whatever it is that cops do in their cruisers during traffic stops, the other remains by our Daewoo and jokes that maybe the last D on the car had fallen off, as he has never heard of the make before, but he knows of an electronics company by the name of Daewood.

The only emotions I am experiencing are shame and embarrassment for having been pulled over. Fear for our safety or even a theoretical notion that a routine traffic stop could turn violent never cross my mind. Despite being egregiously guilty of both offenses, we are sent on our way in our plateless car with neither a ticket nor a written warning. My girlfriend is also white.

 

Playing Fields

It is 2004, and I go back to school for nutrition at the University of Massachusetts Amherst. Driven by a fear of failure, I do everything I can to be academically perfect. In general chemistry, I answer literally every practice question in the textbook, even ones not assigned as homework. In organic chemistry, I attend the TA’s office hours, the professor’s office hours, and the on-campus tutoring department’s study groups every single week. My anxiety drives me to attend chemistry classes that I am not even enrolled in, just so I can hear the material presented over and over again.

My work ethic is as solid as osmium, but so are those of many of my classmates. Unlike some of them, I have finances working in my favor. Whereas some classmates have to load up on courses in order to finish the program as quickly as possible rather than rack up tuition costs for additional semesters, I go at a leisurely pace and never take more than four courses in a given semester. Instead of toiling endlessly at a job just to get by, my part-time gigs as a personal trainer and a dietitian’s assistant rarely sum to more than 15 hours in a given week. While our efforts are more or less equal, theirs are spread thinly over several demands whereas mine are more focused. I can afford – both literally and figuratively – to do this because I have personal savings and financial support from my parents.

Upon graduation, I have a 4.0 GPA, a handful of merit scholarships – including one for my achievements in organic chemistry – and an offer to work for free at one of the most prestigious dietetic internships in the country. Some of my classmates are not matched to an internship and are forced to pivot their career paths away from nutrition.

Because of my financial situation, I can accept my placement in the unpaid internship, the name recognition of which helps me to land my first job as a newbie registered dietitian.

 

The Iceberg’s Tip

It is June 2006, and I am in the early stages of a Seattle-to-Boston charity bicycle ride with a small group of other cyclists from around the country.

Riding into Clark Fork, a small and isolated town in the Idaho panhandle, I am shocked to see Confederate flags and pro-KKK signs openly displayed in front of a good portion of the homes.

That evening, the only black rider on our trip and I head to the local laundromat. As we walk, I tell him how surprised and horrified I am to see that such blatant racism still exists in our country, as I thought that we as a nation were past all that.

He explains to me that because I am white, I have the privilege of moving about the world largely ignorant of racism until it is glaring in my face like it is here in Clark Fork.

He is right, I realize. More than any other lesson that I learn about myself or America during our 4,024 miles across the continent, his is the one that sticks with me.

 

Community

It is the winter of 2007-2008, and my internship rotation has me working on a roving healthcare van that travels to parts of Boston that I have previously steered clear of because I associate them with violence. We park in the heart of Mattapan to conduct various screenings, such as blood sugar and blood pressure checks, distribute free condoms, and answer as best we can whatever health-related questions and concerns are voiced by our visitors, virtually all of whom are black.

On one of our lunch breaks, my preceptor takes me to Ali’s Roti Restaurant because she wants me to experience a cuisine I do not encounter in the suburbs. We browse a neighborhood grocery store so she can show me the food supply available to the neighborhood’s residents. She points out organ meats and animal parts that I never would have thought of consuming before, but they are commonplace in other cultures. Note how prevalent and cheap the sugary drinks are in comparison to other beverages, she tells me. People can only buy what they have available to them and what they can afford, she explains.

We visit a food pantry, and I talk with people eagerly lined up to receive loaves of bread so old that there is no way I would eat them myself unless I was, well, starving. While I know of the existence of food pantries and understand them in an academic sense, this is my first time really experiencing one and interacting with people who rely on them to feed themselves and their families. I go home and make myself dinner in my fully stocked kitchen.

 

Readings

It is the early summer of 2008, and I have just completed my dietetic internship. A seasoned dietitian asks me to help her at a community healthcare event. People will be coming to us for information and screenings, very similar to those that I performed while on the roving healthcare van.

“If you can’t read someone’s blood pressure,” she says, “just tell them it is 120/80.”

The ethical choice and the one that prioritizes patient care is obviously to disregard her directive, but I feel intimidated by her, and I want to stay on her good side in hopes that she might help me with my job search. Fortunately, I am pretty skilled at taking blood pressure, so I never have to cross this bridge.

For our visitors, the vast majority of whom are black, this community event is essentially their annual physical. I imagine someone coming in for a blood pressure check, giving them a fabricated 120/80 result, and sending them on their way thinking they have normal blood pressure when really they have hypertension that subsequently goes untreated and leads to a stroke.

It is June 2020. I read that blacks are 50% more likely to have a stroke in comparison to whites and I wonder: Is the biology of skin pigment really the causal factor here, or is it everything else that comes bundled with being a minority in a country fraught with social disparities and systemic racism?

 

Praising Adele’s Weight Loss Is Fatphobic

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The following is a guest blog written by “Sarah,” a nurse practitioner in the Boston area, who strongly believes in utilizing Health at Every Size (HAES) and anti-diet approaches in both her personal and professional lives. She has been Joanne’s patient for about six years and is in recovery from an eating disorder.

It is no secret that our current society is obsessed with physical appearance. The perceived attractiveness of a person very much determines how they are valued, respected, and treated. This is especially true in regard to women, and to an even further extent, celebrity women. 

At this point, I am sure most of you have come across recent media stories of renowned singer Adele’s dramatic weight loss. After an Instagram post from Adele of herself in a form-fitting dress, with a caption giving a mention of her birthday and a shout-out to the first responders in the midst of the COVID-19 pandemic, comments swarmed in that had nothing to do with what she actually wrote. Now there were some comments that highlighted the fact that we should be praising Adele for her immense talent and not her appearance. Five or ten years ago, some of these comments would probably not have existed, and therefore that does highlight the progress we have made in rejecting diet culture and in the public knowledge of this movement. However, the majority of the comments praised her new, thinner, more “acceptable” body. 

Now I want to make it clear that I know absolutely nothing about Adele as a human, including her diet or exercise regimen. It is truly none of my or anyone else’s business what Adele decides to do or not to do in regard to her body. Even as someone who fully believes in HAES and is very anti-diet, if Adele did intentionally seek a smaller body, I can’t say that I blame her. Our world is a hostile place for those of us living in marginalized bodies. If you are fat, disabled, trans, poor, non-white, or any iteration of these, you are subjected to discrimination and othering. Therefore, it is no wonder why one would want to attempt to fit into a more socially respected body. 

I would normally say that it is unfair to assume anything about Adele’s means of attaining this new look, but in recent articles, she does discuss a particular diet of a VERY scary low number of calories (*trigger warning) and a rigidly structured exercise plan. Again, it is no one’s business how Adele decides to treat her body, but by the DSM standard, there is no question that she would be diagnosed with an eating disorder. I recognize that this is more of a systems issue, and those who mean well by praising her new body are operating under a fat-phobic structure. While eating disorder behaviors are considered concerning when the individual is thin, these same behaviors are encouraged for those who are in larger bodies. It is what we are taught and how we operate as a culture; it is no wonder that full recovery from eating disorders is so challenging (and oftentimes unachievable).

Now let’s get down to the real issue and meaning behind Adele’s weight loss (which really has not much to do with her at all). Body autonomy is part of the HAES movement, and I fully stand behind this for Adele or anyone else. It is the mere fact that a single picture can prompt so many comments (positive or negative) about one’s body that is the core issue here. 

The focus by others on a changing body, in a positive or negative way, often keeps people from recovering fully. If we lived in a world where a body was just a body regardless of how large or small it became, this would not even be a topic of conversation. Although it is an inevitable fact that bodies fluctuate for various reasons throughout the lifespan, we cannot seem to accept this as a society. Naomi Wolf stated: “A culture fixated on female thinness is not an obsession about female beauty, but an obsession about female obedience. Dieting is the most potent political sedative in women’s history; a quietly mad population is a tractable one.” Diet culture and fatphobia are the prime examples of this. We are taught that our worth depends on other people’s evaluation of us and that how our body looks to others matters more than how it feels to us. Especially as women, we are taught that making others happy is more important than making ourselves happy and that the most important thing is that others will like and approve of us, and therefore it is no wonder that we constantly rely on external validation to prove our worth.

Being fat and/or gaining weight is seen as the ultimate failure, and there is countless evidence of this belief expressed throughout history. We see and hear examples of this in our everyday lives, whether we recognize it or not. It is more common knowledge these days that “diets don’t work,” but we have yet to make significant progress in the idea that one’s body does not determine their worth. That is not to discredit all of the amazing progress that the HAES community has made, and as someone in a straight-size body, I cannot speak to the true experience of someone living in a larger, marginalized body. However, as a woman living in constant recovery from an eating disorder, I can say that the fear of weight gain has held me back in so many ways throughout this journey. Fatphobia truly affects everybody (whether they realize it or not) but is much more pervasive for women. 

I now know that these are reactive thoughts stemming from decades of diet culture brainwashing and the instinctual need to belong as a human. These messages have become even louder throughout the COVID-19 pandemic. Not only are we separated from many of our in-person support systems, dealing with real threats to our health and vitality, but we are relatively stuck at home with our thoughts. Although I do truly believe sitting and ruminating in these thoughts and fears can lead to growth in so many ways, it is also extremely triggering. We have less access physically and maybe financially to certain foods, and this can be triggering in itself.

To add to this, those who suffer from eating disorders and also live in larger bodies are especially vulnerable given the extreme fatphobia that knows no boundaries. There have been countless news articles claiming that people living in larger bodies are more susceptible to COVID-19. Not only is this untrue, but it is incredible healthism and just another example of diet culture profiting from our fears. Attempting to change one’s body size in the hopes of health and immortality has never worked in the past and scientifically never will. It is disappointing that these messages of blame and shame are being touted instead of compassion, inclusivity, and actual scientific facts, especially during this time. 

So how do we begin to change as a culture? By recognizing that beliefs and facts are not the same. By rejecting diet culture and recognizing that our body size or health status has nothing to do with our worth as humans and by treating others with respect and dignity just because they exist. As the wise Ragen Chastain said best: “Health is not an obligation, barometer of worthiness, or entirely within our control,” and this could not be more relevant in our current climate.

Emotional Eating in Quarantine

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Despite the major life disruption that the coronavirus quarantine has been for us personally, Jonah and I are lucky enough to be able to still work, as we are telehealth providers. While all of my patients are struggling in different ways with quarantine, one theme keeps on popping up consistently: “I feel like my emotional eating is out of control.”

Many of my patients are working on becoming intuitive eaters, and the current pandemic is making it extremely difficult for them to heal their relationship with their bodies and food. Living in these strange times is like nothing we have ever experienced before – being confined to our homes, socially distancing, and the near constant underlying fear of illness are exhausting and emotionally draining.

Some of my patients are working on the front lines of the corona crisis, taking care of patients who are severely ill. Some of my patients have lost loved ones to the virus. Others are struggling with the loneliness of isolation. In short, the past couple of months have been really, really rough. And the fact that there is no definite end point for this pandemic, that this state of limbo could continue for months on end, leaves many of us feeling hopeless and trapped.  

So when my patients tell me that they are emotionally eating, I am not at all surprised. Emotional eating in times of stress and uncertainty is normal and, honestly, to be expected. From the time that we are born, food is a source of nourishment and comfort. Food is a basic human need. From the very beginning, whether we start out nursing or bottle feeding, drinking breast milk or formula (or both), food is necessary for survival. It is designed to make us feel satiated and safe. Food is one way that our caregivers take care of us when we are babies, providing comfort when the feeling of hunger arises. This is all to say that turning to food for comfort is a completely normal thing for humans to do – it is programmed in our DNA. And feelings of comfort and safety are paramount to developing love and attachment.

The phrase “emotional eating” has been around for many years, and it always seems to be presented as a negative thing. Many of my patients characterize themselves as emotional eaters and wish that they could stop. In most cases, these patients feel as though they have “no control” around food, that they will overeat on certain comfort foods, and they inevitably feel shame after they do this. Of course, many of these patients are consumed with fears around gaining weight and feel that by engaging in emotional eating, they are likely to become larger.

To me, “emotional eating” is a phrase that was created by diet culture because at the root of it is fat phobia. Our culture is a completely fat phobic one, and one of the underlying themes is that engaging in emotional eating is a dangerous habit; if one emotionally eats regularly, they will gain weight, become fat and be unhealthy, unattractive, and unlovable. Emotional eating is seen as problematic by diet culture, and those who engage in it are deemed weak-willed and less than.

In my work, what I have found is that the amount that a patient engages in “emotional eating” is almost directly proportional to the amount of restriction (both mental and physical) in which they also engage. In other words, my patients who feel like they are emotional eaters and cannot control themselves around food are often the ones who are the most restrictive with their intake.

If you think about it, it makes sense on a biological level. Our early ancestors were often subjected to famine and food scarcity, and in order to survive during those times, their sole focus became about finding food. It is one of our most basic survival mechanisms, and it is deep within our genetic code. When we are deprived of food (whether it be deprivation imposed on us by others/circumstance or self-imposed), our primal brain is designed to focus solely on procuring food. And not just any food, mind you, but food that is calorically dense and will give us quick and lasting energy, specifically foods that are high in carbohydrates and fat. Is it any wonder that many of our “comfort foods” are often comprised mainly of carbs and fat? It is our ancient genetic code’s way of keeping us alive.

This is all to say that when we are in times of stress, anxiety and fear (like during this pandemic), it makes perfect sense that we might turn to food for comfort more often. This behavior in and of itself is not problematic; it is one of the many ways that humans cope during difficult times. Add on top of that feelings of deprivation around food (with many grocery stores running out of supplies and access to restaurants reduced), and it is no wonder that we have food on the brain more often as well. The most important thing we can do right now is not to judge ourselves for “emotionally eating” during this tough time, but to have some compassion for ourselves. We are all just trying to take care of ourselves in the best way we know how.

Welcome to Food Insecurity

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The pasta aisle at the Wellesley Whole Foods on March 13, 2020.

Some of the earliest dietary guidelines emphasized high-calorie foods, like butter and margarine, because so many young men were failing their military physicals due to malnutrition. Unlike some of our ancestors, who struggled through or perished in famines or economic depressions, my generation in this country has been lucky in that we could take our access to food for granted.

Of course, numerous exceptions exist. Needham’s food pantry and the SNAP stickers on supermarket refrigerators are evidence that some of our very own neighbors struggle to get enough to eat. When I visited grocery stores on isolated Native American reservations in middle-of-nowhere regions of Montana and North Dakota in 2006, I was floored by how limited the selections were. Poverty and food deserts are not the sole factors that can limit access to food, as some of my pediatric patients growing up in restrictive households could tell us. Dieters know that food scarcity can be self-imposed.

For the rest of us, the panic surrounding COVID-19, the associated hoarding of supplies, and the resulting empty shelves have inducted us into a sensation that so much of the human race has known, but we were too privileged to experience it firsthand.

Welcome to food insecurity.

Whether or not our food supply chain is actually at risk for significant disruption, the mere perception of a threat is enough to trigger feelings of food insecurity. We see the pasta shelves and potato bins empty, the milk section vacant, frozen produce nowhere to be found, and other typical supermarket staples gone, and we feel a visceral reaction that we had better get what we can while we can. Hence, we hear stories of people making purchases that in other circumstances would make little sense. For example, one of our patients was at Costco and ended up buying a gallon of mayonnaise, a condiment she does not even typically use, just because she could get her hands on it in the midst of the frenzy.

We can understand why. Dieters know that restriction, or the mere threat of it, triggers overconsumption. Thematically, little difference exists between someone loading up a shopping cart with whatever items they can and a person who overeats on the weekend while telling themselves, “Diet starts Monday.”

When it comes time to eat, the veil of food insecurity might compel us to finish all that we have served ourselves, lest we “waste” food by leaving it uneaten. My suggestions are to understand the source of these feelings and to validate them, but also to realize you still have a choice and remove moralization from whatever decision you make.

Keep in mind that we have in our lineage ancestors who survived extraordinary circumstances and may have attempted – for better or for worse – to instill their survival skills in us. For example, my grandparents, who grew up during the Great Depression, used to pressure me to clean my plate. As another example, one of my patient’s grandmothers is a Holocaust survivor and made it through her horrific ordeal by eating whatever she could whenever she could because her next feeding opportunity was never guaranteed; like my grandparents, she pressures my patient to eat more than he can comfortably consume, too.

In terms of what to do about potential overconsumption, there is no blanket answer that is right for everyone. Instead, I encourage people to be aware of the dynamics involved in their eating decisions, including any pressures and threats related to food insecurity that might be at play.

Consider the role that stress might have in your eating decisions and know that – contrary to what diet culture tells us – emotional eating is an understandable and relatively benign response to these troubling times. We all have to deal with our stress somehow, and each of us has a different toolbox of coping strategies. Before you feel badly about eating extra in an effort to soothe yourself, remember there are people in your neighborhood reacting to their stress in much more destructive fashions, such as shooting heroin or beating up their spouse. Eventually, we can expand our repertoire of coping options so that eating is just one of many choices we can make to de-stress.

Ultimate decisions matter less than having taken the time to thoughtfully arrive at them. Weigh the pros and cons of whatever options you face while understanding that none of them is likely perfect, choose the one that in balance feels the most right to you, and know that you are neither guilty nor virtuous for whatever choice you make.

Keep in mind that these times will not last forever. Quarantines and social distancing directives will end, restaurant dining rooms will reopen, and grocery store shelves will be fully stocked once again. When they do, be on the lookout for residual behaviors that may date back to your days of food insecurity, as we know from our ancestors that such behaviors can stick around long after the threat is gone.

No Bargaining Needed

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About a month ago, I was watching one of my usual TV shows when a commercial came on for Ore-Ida French fries. Normally, I would skip ahead using my DVR fast forward button, but something made me pause. The commercial starts with a young girl and her father sitting at the family dinner table. The girl has a plate with broccoli on it. She pushes it away with a look of disgust on her face, her father pushes the plate back in front of her, and this gets repeated a couple of times until dad whips out three crinkle cut French fries in his hand. Immediately, the girl smiles, takes a bite of her broccoli, and then happily grabs the French fries. Meanwhile, the voiceover narrates: “Is mealtime a struggle? Introducing Ore-Ida Potato Pay. Where Ore-Ida Golden Crinkles are your crispy currency to pay for bites of this [broccoli] with this [French fries]. When kids won’t eat dinner, Potato Pay them to. Ore-Ida. Win at mealtime.”

Um, what now? Wow. Now, as the mother of a toddler who isn’t the most adventurous or enthusiastic eater, I get that parents often struggle at mealtimes with their kids. As parents, especially parents of young children, we are the “gatekeepers” of meals and snacks, deciding what food will be served and when. There is a lot of pressure on parents to make sure their kids are getting just the right amount – not too much, not too little – of nutrient-dense foods to ensure optimal health. Even prior to birth, mothers are reminded to eat as nutritiously as they can to give their developing baby the best chance of being healthy. This concern continues with infants, as many parents struggle with figuring out if breastfeeding, bottle feeding, and/or formula works best for them. And as these infants grow and eventually start eating solids, the worries about getting enough nutrition while avoiding “empty calories” commence. It’s stressful to be in charge of what your kids are eating (or not eating)!

As Jonah and I have written about previously, we believe that Ellyn Satter’s Division of Responsibility (DOR) is the best way to help one’s children become competent intuitive eaters. In short, the DOR states that parents or caregivers decide what food will be served, at what intervals food will be served, and where food will be served. Children, on the other hand, are in charge of eating (or not eating) the offered food and how much they eat of said food. Parents/caregivers are encouraged to offer a wide variety of foods at meals and snacks, including not only “nutrient dense” options but also foods that the general public might consider to be “fun foods” that are high in sugar, fat, and/or salt. When using these strategies, children learn to trust their hunger and fullness cues, develop their palates, and learn to eat in a satiating and enjoyable way. They also learn that foods don’t have moral value; for instance, broccoli isn’t inherently superior to French fries, and all foods fit.

Clearly, bribing your child to eat their vegetables (or other foods they don’t want to eat) with “fun foods” is the exact opposite of the DOR. This teaches kids that they can’t trust their own bodies to tell them what and how much to eat. It teaches kids that the only way to eat broccoli is to choke it down in order to earn French fries. It takes all agency away from the child and turns the parent/caregiver into the food warden. Instead of helping kids try and figure out what foods they enjoy (which could include broccoli!), this technique basically punishes kids for having preferences. It can and will create even more stress and power struggles around mealtimes.

Look, I get it. I, myself, have had to curb my instinct to try to push more “nutritious” foods on our daughter when all she seems to want to eat are the high fat, salty or sugary foods. I want her to be healthy! I don’t want her to have nutrient deficiencies! But I also have to remind myself that intervening in her side of the DOR is overstepping my bounds and that by putting some foods up on a pedestal and pushing them on her, I would be teaching her that foods are either “good/healthy” or “bad/unhealthy.” Instead, I want her to know that all foods fit and that I trust her body to tell her when it is feeling more in the broccoli mood or in the French fry mood. I know that she will eventually get plenty of messages around food from her peers, teachers, and TV, but I hope that by instilling the principles of intuitive eating and DOR early on, I can prevent her from getting sucked into diet and wellness culture.

WHETHER U BELIEVE U CAN OR CAN’T ONLY SOMEWHAT MATTERS!

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Anything is possibleeeeeeeeeeeeeeeeee!” Kevin Garnett was already one of my favorite basketball players long before he came to Boston and helped the Celtics to win the 2008 championship, but his famous post-victory line made me cringe. No, Kevin, while I understand you were excited and trying to inspire, empower, and motivate, let’s be real: Anything is not possible.

The message board outside Needham’s Mitchell Elementary School triggered a similar reaction when I passed by it earlier this month. “WHETHER U BELIEVE U CAN OR CAN’T YOU’RE ABSOLUTELY RIGHT!” What are we teaching the children in this town, I questioned, and I am not even referencing the problematic grammar that seems to acquiesce to the texting generation.

As someone who was raised on The Little Engine That Could, I can appreciate the power of motivational messages that encourage children to believe in themselves, show courage, and put forth their best efforts. After all, sometimes we sell ourselves short and assume something is out of our reach, when really we could have grasped it if only we took a chance and tried.

However, the little engine’s famous mantra is “I think I can,” not “I know I can,” and the difference of just a single word reflects a broad and important truth: While we can control our behaviors to an extent, outcomes depend on more than just our actions and are often subject to factors that are out of our hands.

Competitive runners learn that time is more in their control than placement, as the latter depends on who else is racing. For example, I may go into a race fully believing in my heart that I can finish in the top ten, but if the Kenyan national team shows up to run, all the self-belief in the world is not going to overcome my competition’s skill. Even finishing time, which is more in one’s control than placement, is still subject to exterior forces, such as weather, that can slow down the entire field.

Life experience has taught me that someone using the language of certainty, such as the verb “will,” when discussing outcomes that are only somewhat in their control is a red flag that the person has lost some touch with reality. One of my first jobs as a dietitian was at a startup medical clinic that boasted that they would expand to 50 locations across the country and build a headquarters complete with a farm and even their own medical school. The leaders disapproved of and took exception to pragmatic questions about the feasibility of their stated goals and used language of certainty when discussing the company’s future. A few years after I left the company, they went out of business completely, having expanded to a total of two locations.

My gripe with the quote outside Mitchell School is not technical, unlike the guy who used logic and mathematics to pick apart the semantics of Wayne Gretzky’s famous quote; nor is it theoretical, as if I were overly worried about a potential impact that may never come to fruition.

Rather, my concerns are based on real experiences I have had with my patients, including children, who cite these sorts of motivational quotes as justification for putting themselves in harm’s way. This most commonly occurs in the context of a desire to lose weight, as some children have told me that they believe they can lose weight and keep it off if only they try hard enough.

While I admire their self-confidence, which will likely serve them well in so many other areas of life, weight regulation is the wrong place to assume that belief in oneself and hard work is enough to get the job done. The truth is that while numerous methods of inducing short-term weight loss exist, nobody has demonstrated an ability to produce long-term weight loss in more than a small fraction of the people who attempt to achieve it.

Some research has found “almost complete relapse” after three to five years, other data are more specific and suggest 90% to 95% of dieters regain all or most of the weight within five years, while other research has found that between one third and two thirds of people end up heavier than they were at baseline. Research in adolescents has found that dieters were three times more likely than non-dieters to become “overweight,” regardless of baseline weight.

To suggest that the people who regain weight simply did not believe in themselves ignores the reality that behaviors play only a small part in weight regulation while factors out of our hands, such as genetics and our gut microbial population, are largely responsible. As an example, consider folks with atypical anorexia nervosa who can implement life-threatening levels of restriction without experiencing weight loss.

Unfortunately, striving for weight loss is not a benign pursuit in which the worst-case scenario means that one simply returns to where they started. Research has shown that weight cycling – repeatedly losing and regaining weight – is associated with numerous health problems, including a higher overall death rate and an increased risk of dying from heart disease, regardless of one’s baseline weight.

Teaching self-confidence is important, but I think we can do better than overly simplistic messages that children can – and will – take literally to their own detriment.