“If you’re gay, don’t come home.”

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Joanne and I overhear so much nutrition-related garbage at our health club that I have considered creating a new blog category to chronicle it all, the working title of which is “Shit We Overhear at the Gym.” Harsh, but to the point.

Similarly candid and blunt was my experience at the gym this morning, where the topic of conversation was understandably a departure from the typical diet talk, body shaming, and nutrition myths, and instead focused on the presidential election results.

“My husband told me, ‘Anybody but her [Hillary Clinton]’, but I am really scared, and as a woman I feel so disrespected,” said the woman on the cable machine. Shortly thereafter, I ran into a friend of mine who fought back tears as she talked about what Trump’s election means for her 18-year-old daughter who now fears for her present and future.

Once I finished my workout, I headed downstairs to the men’s locker room where the guys were also discussing the election, but instead of crying they were laughing, making a joke of the whole thing. The sample size is small, granted, but the stark contrast between the male and female reactions illustrates the difference between the privileged and the vulnerable.

A friend of mine, someone I have known for close to 30 years, is the only open Trump supporter in my social circle. Once his candidate was declared the victor, he took to Facebook and gloated. After considering whether or not to respond, I decided to reach out to him in a way that I thought might help him to understand what this election result really means for our country.

When we were teenagers,” I wrote, “your father reportedly said to you, ‘If you’re gay, don’t come home.’ Fortunately, you self-identified as heterosexual, but the threat of not being accepted and welcome in your own home shook you enough that you talked with me about it. A Trump presidency makes America a less welcoming and more dangerous place for Muslims, Jews, Mexicans, women, blacks, gays, and other at-risk groups. The outrage and fear we are witnessing regarding Trump’s election is not about political parties, a change in direction, or disagreement over policies; rather, it is about millions of people with whom you and I share this country waking up today worried for their safety and freedom.

“For your sake, I am glad the crosshairs are not on you, at least not yet. Hopefully neither one of your sons is a closeted homosexual or self-identifies as a woman but is too scared to say so. For the rest of us, whether we are members of one of Trump’s targeted groups or we simply care about the people who are, his election is an ominous reminder that hate and scapegoating are alive and well in America and that history can certainly repeat itself.”

Hate is nothing new and Joanne and I have received a small taste of it. Because we advocate for size acceptance, we are occasionally bullied by online trolls who disagree with our stance that everybody, regardless of their size, is entitled to respect and equal treatment. The flack that we catch is nothing; for some of our colleagues, daily death threats are a way of life.

What is new though is the legitimacy that Trump has given to hate. Hiding behind an anonymous Twitter handle or a white sheet was one thing, but suddenly we had a presidential candidate repeatedly broadcasting his racism, misogyny, and bigotry out in the open on international television, and instead of shutting him down, we elected him. No wonder the women in the fitness center cried while the guys downstairs laughed.

As paradoxical as it may sound, intolerance of intolerance is an important stance for the safety of our community. Employees who spout hate speech at work are likely to be disciplined or fired, our legal system has hate crime laws that extend beyond whatever act is committed, and Germany banned the swastika after the fall of the Nazi regime, just to name a few examples. Regarding the latter, I reminded my friend how things worked out for that country and its people when a man rose to power on the platform that minorities were to blame for the nation’s poor economy and lack of prosperity.

We, as Americans, should be ashamed of ourselves. All of the men and women who have given their lives, either literally or figuratively, in military conflicts and civil actions over the past 240 years in pursuit of freedom and equality, and now a good portion of our citizens are eagerly trying to flush it down the toilet. We are a threat to ourselves and the world. America is an international embarrassment.

Joanne and I both want to leave. She says Toronto, I say Canada is too close for comfort and have my sights set on New Zealand. In reality though, running from the problem is no solution and we are not going anywhere. Every generation faces its struggles with hate, but the overall trend moves towards acceptance and inclusion because ordinary people hold their ground, stand up, and demand it.

Gentlemen, the Ladies Do Not Hold a Monopoly on Weight Obsession

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Gentlemen, the ladies do not hold a monopoly on weight obsession. Us guys engage in diet talk and body shaming, too. You know that, right? Maybe not, actually, as such talk is so casual and commonplace that you might not even be aware (consciously, anyway) of its pervasiveness. Consider the interaction I had yesterday evening at the gym with a male acquaintance we will call “Brad,” whom I had not seen in a long while.

Brad walked past me as I was warming up on the Arc Trainer prior to a tennis match. He had just finished a spin class and stopped to say hello. Brad and I first met 16 years ago while taking a core-strengthening class together, but the only place I had seen him in recent years was when we occasionally bumped into each other at the local pub where he eats dinner every Friday.

“You’re in nutrition. What do you order when you go there?” Brad asked with a smirk. Although he did not specifically say so, I knew exactly what he was getting at: He wanted to know if I follow a strict diet or eat freely like a perceived hypocrite, hence the mention of my profession.

Pausing, I considered the various replies at my disposal. On one hand, this was an opportunity to reeducate Brad regarding both the nature of my work and the problems with a good/bad food dichotomy. On the other hand, this was also my free time, and really I just wanted a few minutes to myself to get loose before heading out to the court, not an obligation to broach complex topics when I had neither the time nor inclination to do them justice.

“I order what I want,” I finally told him. “I order what feels like the best choice for my body at the time,” and specifically cited the pizza and nachos, which are my salty favorites to replenish the sodium I lose during long runs. (Note: By no means am I implying that one needs to exercise in order to “earn” these menu items or any other food.)

Then I asked him if he has seen our mutual friend (Let’s call him “Gary.”) who resumed exercising earlier this year after a long absence. “He’s down 40 or 50 pounds,” Brad responded, “He looks great!” Again, I paused and internally debated my next move. At the very least, I knew there was no way I would echo Brad’s praise for weight loss, as I know the damage such extolment causes, especially without fully knowing how or why someone lost weight.

“Weight loss aside, I’m just glad he is taking the time to care for himself again,” I told Brad. Like me, Gary was an avid exerciser, which is how he and I met at the gym soon after I graduated from college, but the burden of his caretaking duties increased as the health of his parents deteriorated and he no longer felt up to working out. His mother and father subsequently passed away in quick succession, which left Gary to settle their estate and figure out what to do with his own life. After everything Gary had been through, I was just happy to see him caring for himself again and returning to the activities he enjoys, including exercise, regardless of his weight.

Unfortunately, Brad did not seem to follow the gist of my sentiments and continued talking about Gary’s weight loss, adding that he has seen Gary do this at least a few times before. By “this,” Brad was referencing Gary’s history of weight cycling: alternating periods of weight loss and subsequent regain. “But not like you have to worry about that yourself,” Brad offered, looking down at my abdomen. “You’re always in great shape.”

Great shape? One of the problems with judging people for their exteriors is that we probably have no idea about the makeup of their interiors, both metaphorically and literally. Too taken aback by Brad’s comment to say anything out loud, I silently reflected upon everything I have been through over the last three years and specifically turned my thoughts to the titanium screws and rods, artifacts from my third back surgery, buried deep inside the midsection of which Brad is apparently so envious.

As is the case for everybody, my size and shape are influenced by many factors, the most significant of which are out of my hands. Among those that are at least somewhat in my control though is my history of never having tried to lose weight, which would have put me on a path most likely to end at, ironically enough, weight gain. In that sense, part of the reason I do not have a “weight problem” is because I never viewed my weight as a problem.

Think about the diet talk and various mentions of body shape and weight that Brad crammed into a casual conversation that lasted just a few minutes. Comments and discussions along these lines are so prevalent that I overhear men talking this way at the health club on a daily basis. Another recent incident comes to mind in which some of my fellow tennis players – adults, no less – bullied another player for the size of his stomach.

The problems with such talk are numerous, including: the reinforcement of the ridiculous, offensive, and dangerous notion that people of certain sizes and weights are more deserving of respect than others; the exacerbation of bullying and unequal treatment that spills well beyond health clubs and into our homes, businesses, classrooms, government initiatives, and doctor’s offices; and the pressure to pursue weight-loss endeavors that most often result in weight gain and worsened health.

Guys, this kind of talk has to stop, and the first steps toward putting it to rest are acknowledging its existence and realizing the harm we are doing to each other through our words.

One Week in October

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October 15, 2016, Ludlow, Massachusetts

Exactly 941 days after my first spinal fusion and 472 days after my second, I drove west to play a match for my old Amherst-based United States Tennis Association (USTA) team for the first time in a decade.

Over those 10 years, and particularly in the last two as I recovered from my operations, I dreamed of reuniting with them and wondered if it would ever actually happen. Intellectually, I thought it might, as my surgeon was cautiously optimistic about my chances of playing competitively again. My physical therapist was more guarded, however, particularly because the failure of my 2014 surgery reinforced that medical outcomes are rarely guaranteed no matter how certain they may seem on paper. So while in my head I thought I might compete again, in my heart I never really let myself believe it for fear of crushing disappointment.

The team roster has undergone some turnover since I last played for them in 2006, but many men still remain from my first stint and it sure was great to see them again. “You haven’t changed at all!” one of them declared. Well, on one hand, I think of the transitions I have experienced in the last decade: no longer a student, now a licensed healthcare practitioner; no longer an apartment-dwelling bachelor, now a husband, homeowner, and business owner; no longer a spry 20-something, now a balding guy in the twilight of his 30s with three back surgeries under his belt.

On the other hand, I felt at home again, just as I had before, that much was constant, and I think my teammate could see it in my face. If anything, I felt even more confident walking onto the court now than I did back in the day. Just returning to the team was in itself a victory, so whatever else I happened to achieve in the match was a bonus.

Confident and relaxed, I took advantage of an opportunity a decade in the making and destroyed my opponent 6-1, 6-0. As I quipped to my team captain, “Those 10 years of rest really helped!” Most importantly, my back felt great before, during, and after the match, which was particularly noteworthy considering what my body went through just six days earlier.

October 9, 2016, Newport, Rhode Island

My surgeon cleared me to resume running in January and I quickly ramped up my training enough to complete a 10-mile race in late February, but subsequent pain suggested that sticking to shorter distances was probably in my best interest. As the spring progressed, however, I was able to comfortably go for some longer jogs, which had me wondering if running the Newport Marathon in October might be possible. In July, my surgeon reversed his stance on long-distance running, gave me his blessing, and told me to go for it.

Go for it, I almost did not, as I nearly backed out several times on the morning of the race. As recently as two days earlier, I was excited for the event and did not feel the slightest bit nervous, but in the final hours I was sad and anxious, eerily similar to how I felt on the mornings of my surgeries. Driving south on route 24 before dawn, I thought about how easy it would be to take an exit, any exit, turn around, head north, and crawl back into bed. Just continue on to Newport, I told myself. Do not make a decision about the race yet, just drive to Newport, park, and reevaluate.

The parking lot near the starting line was still pitch black when I arrived, and torrential rain and raging winds, the extension of Hurricane Matthew that reached New England, pummeled me as soon as I stepped out of my car. Retreating to my vehicle, I considered pulling out of my space and driving home. Instead, I paused to take a deeper look at my anxieties, which mostly centered around getting sick or injured, and reminded myself of the strategies I had formulated to avoid disaster and maximize my chances of a great race.

Most importantly, I remembered other instances in my life when I felt similarly stressed and apprehensive before significant events, most notably my transcontinental bicycle ride a decade ago, only to be happy that I had followed through. In the early morning hours of June 1, 2006, my best friend drove me to a Seattle beach, my bicycle and backpack in the trunk. Sometimes he reminds me just how petrified I looked as we sat there waiting for the other riders to arrive. Indeed, part of me wanted to curl up in the fetal position in his passenger seat and ask him to drive me back to Seattle-Tacoma International Airport. Out of the 4,024 miles I traveled between Seattle and Boston, the most difficult span was the step out of his car, but I am so glad I took it.

“If you get out and run,” I told myself, as I remembered my bike trip, “in about six hours you are going to sit back down in this car seat with a medal and a tremendous sense of accomplishment.” So that’s what I did: I got out and ran. Around mile 24, I passed by my car and thought about the pep talk I had given myself early that morning. Soaking wet from the storm but excited and still full of energy, I finished the course with the fastest two miles of my entire race.

As was the case regarding my aforementioned tennis match, my back held up just fine during the marathon. “I don’t know if you fully appreciate how impressive that is after all you have been through in the past few years with your back and the surgeries,” my physical therapist wrote in an email. She may be right, as she can speak better regarding typical clinical outcomes than I can, but by no means did I take being able to complete a marathon for granted. Finishing was emotional, not just because of how close I came to backing out of the race that morning, but because for a long time I thought I would never cross another marathon finish line again.

Three days after the race, I returned to my surgeon’s office for a routine follow-up appointment. “I brought something to show you,” I told him, as I reached into my jacket pocket and retrieved my finisher’s medal. “Wow,” he laughed, “That’s amazing!” Back in March, he had gently told me my days of running marathons were probably over. He was right; they probably were.

October 8, 2016, Boston, Massachusetts

Walking from the Hynes Convention Center subway stop to its namesake for the final day of the Cardiometabolic Health Congress, I remembered limping the same route three years earlier, physically unable to continually walk the two blocks without pausing for my back pain to die down.

About a week before that day in 2013, I went to bed feeling fine, but in the morning I stood up from bed and almost fell over due to a sudden onset of severe pain radiating down my leg. Over the next few days, I hoped the symptoms would resolve as spontaneously as they arose, that I would similarly go to bed and wake up in the morning feeling back to normal. As I struggled to walk from the subway to the convention center, however, reality set in that a rapid recovery was not in the cards and I might be in serious trouble.

Thus began my three-year saga of doctors, injections, medicines, physical therapy, alternative treatments, surgical consults, operations, setbacks, and rehab that led to the present. This road has no end, as I will always have to be mindful of my back, take care of it as best I can, and live with the uncertainty that someday I may run into trouble with it again despite my efforts, but I am very happy and thankful to be where I am today.

He Said, She Said: Sports and Nutrition

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He Said

Leading up to this month’s Newport Marathon, I solicited advice from colleagues around the world as well as fellow marathoners regarding fueling strategies that might help me to avoid the nausea that plagued me in earlier endurance events.

The suggestions I received were all over the place: Eat boiled potatoes with salt late in the race. Pack maple syrup in a fanny pack and drink it periodically along the course. Eat bananas, orange wedges, gummy bears, white bread, salt bagels, or jelly beans. Drink Gatorade, Pedialyte, flat beer, coconut water, Nuun, Skratch Labs, or mix the latter two together.

As I sifted through the various suggestions, I realized I was looking at a great example of the intersection between the hard science of nutrition and intuitive eating. During endurance events, we need to replenish fluids, carbohydrates, and electrolytes, but how we do that must be individualized based on what works for each one of us; thus we need the gamut of ideas. How we determine what works best for us is by trying various approaches based upon sound nutrition guidance and personal history, paying attention to how each trial makes us feel, and basing new iterations largely on firsthand experience.

Sometimes we, as patients, have a tendency to defer entirely to our practitioners. We see comfort in directives. “Just tell me what to eat,” a patient may say. In reality, a collaborative approach tends to be much more effective in part because determining the best path involves the patient’s input and experiences. Hydrating with a particular beverage may seem great on paper, for example, but if it disagrees with the patient’s system, then we need to form a different strategy.

Patient input is one of the most significant differences between textbook nutrition and nutrition in real life, which is why Joanne and I strive to create an atmosphere of collaboration and equality at our practice. Only our patients know how various foods make them feel, so we focus on building intuitive eating skills in part so they are able to recognize and communicate these experiences.

Leading up to the marathon, I treated every athletic endeavor as an opportunity to experiment and gather data regarding how various foods and fluids made me feel. One of the drinks I tried during a tennis practice failed to hit the spot whatsoever, but better to find that out during a casual hitting session than during an important training run or the marathon itself. Another beverage worked really well once I was actually running but made me jittery beforehand. Some foods gave me cramps and made me feel sluggish whereas others settled better than I expected. All of these outcomes, even if they were not what I had hoped, represented important data.

As a result of my experiments, I knew exactly what I was going to eat and drink come race day. Breakfast consisted of white toast with peanut butter, honey, and sliced banana with orange juice and Nuun Active. Between breakfast and the start of the race, I drank Gatorade and water until a half hour before the start, at which time I downed more Nuun Active. During the race itself, I consumed Gatorade and bananas from the aid stations as well as Nuun Energy and salted pretzels that I brought with me. Worked like a charm.

If your takeaway from this column is that you should adopt my own specific food and hydration plan during your own athletic events, then unfortunately you have missed the point: the importance of individuality. As I downed the last of my Nuun Active before the start, my friend with whom I ran the race strapped small vials of maple syrup to her waist, a fueling technique that she knew from experience would work for her. If she and I had swapped strategies, both of us would probably have felt awful. We are all different, so figuring out what works best for you is a process that involves both guidance from a professional as well as your own input based on firsthand experiences.

 

She Said

From a young age, I participated in a variety of team sports, including soccer, softball, and volleyball. While I truly loved playing these sports, my family was a tennis family, in that tennis was a sport that we all learned to play as children and enjoyed playing together. As I got older, I played tennis less and less, usually just hitting the ball around for fun with my family on vacations or with Jonah on a public court during the summer. But about 3 years ago, I decided to get back into the sport that I had enjoyed so much in my youth, so I joined several local women’s tennis teams.

While my overall experience on these teams has been overwhelmingly positive, whenever the topic of food or weight comes up, I have noticed some troubling trends. Whether it is one of my teammates or one of our opponents, a number of these women exhibit quite disordered ideas about food and weight.

When I was new to one of my teams, I remember one of my teammates asking me what I do for a living. After I told her that I work primarily with individuals struggling with eating disorders (EDs), she jokingly commented, “Oh, I so wish I had an eating disorder! I just can’t seem to lose these pesky 10 pounds!” I was very quick to correct her and explain how dangerous and life-threatening EDs are and that they are not simply something that someone can choose to engage in or not to lose a few pounds.

In addition to misunderstanding EDs and the seriousness of these disorders, many of the tennis women I encounter seem to struggle with diet mentality. A couple of years ago, I remember one of my tennis friends casually mentioning that one of the primary reasons she plays so much tennis is that it allows her to eat whatever she wants. In fact, I have heard this sentiment from other tennis peers, implying that they view tennis first and foremost as a way to burn calories.

At nearly all of my tennis matches, the home team provides food for the visitors and themselves. Depending on the time of the matches, the foods offered can range from simple snacks to pretty substantial lunches. Of course, with all of this food come a lot of shame, guilt, and judgments. I overheard one group of ladies on an opposing team debating whether they would have one of the cookies offered, with one of them declaring that she does not allow herself any “white carbs.” Other times I have seen women eating only salad or protein, as they are “trying to be good.”

Diets are a hot topic at many of my matches and practices. From Paleo to Whole 30 to Shakeology, a great number of the tennis women engage in restrictive eating in one form or another. One of my tennis friends started a cleanse not too long ago because she felt like she really needed to “detox” her liver and other organs. Another friend has been eschewing carbohydrates during the week and only indulging in them on her “cheat days.” As one might imagine, I try not to engage in any diet conversations as they can become quite charged. But when I mention what I do for a living, it seems like many of these women are only too happy to talk to me about food and nutrition.

I really don’t blame these tennis ladies for their disordered ideas about food, nutrition, and weight – they are subject to the numerous fear-mongering messages we all receive from our doctors, from the media, and from our friends and family. Talking about one’s diet or weight has become so commonplace that the idea of not talking about it seems strange somehow. But just think about all of the other things we could discuss! All of the ideas and stories we could share with each other! Wouldn’t that be more fun than talking about how to lose those pesky 10 pounds?

At the end of the day, I try to pick my battles. If someone asks me about my thoughts on dieting or certain foods, I will oblige. I try to be gentle with them around my strong anti-diet philosophy as it can be quite surprising and confusing for many people. When it comes to EDs, I do my best to educate those who ask about them. So far, many of my teammates have expressed interest in the idea of intuitive eating and the non-diet approach, so I have tried to point them in the right direction by recommending books and other resources. If I can somehow help even one of them to ditch the diets and begin to appreciate their body for what it can do (e.g., play tennis!), then I will feel like I have made a difference.

He Said, She Said: Obesity Awareness Month

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He Said

The concept of National Childhood Obesity Awareness Month is flawed in several ways, many of which Joanne covers in her She Said passage. The most glaring issue, in my opinion, is that by promoting the use of weight as a proxy for health, the government is paradoxically distracting from matters of actual health.

Human beings can be healthy at a variety of weights, which is why we cannot draw accurate conclusions about someone’s health or behaviors based solely on their size. Thin folks can have plenty of medical woes. A couple of years ago, I wrote about a slender friend of mine who was diabetic, suffered a heart attack, and ultimately died of cancer. Someone might be thin due to food insecurity, a medical condition, psychological disturbances, eating disorders or disordered eating, or overexercise, just to name a few of the health-threatening issues that might lead to lowered body weight.

With a focus on obesity, not only do we miss an opportunity to identify and assist people at risk for or suffering from these problems, but we actually push them in the direction of trouble. For example, I have recently seen an increase in pediatric patients, including males, with eating disorders or disordered eating that reportedly stemmed from a fear of getting fat brought on by discussions at school or the doctor’s office.

One of my teenage patients recently told me how his pediatrician praised him for having lost weight from one annual checkup to the next after having chastised him the year before, but what his doctor did not know was that my patient had overexercised and restricted his food intake leading up to the appointment for fear that his doctor would again be mad at him if he had not lost weight. My patient’s behaviors brought him further away from health, not towards it, and the poor communication between him and his doctor puts him at risk for improper care in the future. Furthermore, food restriction elevates his risk for binge eating disorder and, ironically, ultimate weight gain.

Trust me, children who are obese already know it. They hear about it on the playground, in gym class, on television, online, maybe in the pediatrician’s office, and from other sources that tell them something is wrong with their bodies and it is their fault. National Childhood Obesity Awareness Month calls even more attention to them and their bodies, thereby exacerbating stigmatization and bullying.

The concept of National Childhood Obesity Awareness Month may be well intentioned, but its fallout is the exact opposite of the desired effect. If we want to improve the actual health of our children, better to promote size diversity and the importance of healthy behaviors, such as fun and appropriate physical activity, for everybody.

 

She Said

According to the U.S. Department of Health and Human Services (HHS), September is National Childhood Obesity Awareness Month. Per the HHS website, “one in 3 children in the United States are overweight and obese,” putting kids at risk for developing health problems such as type 2 diabetes, hypertension, and heart disease. The website goes on to say that childhood obesity is preventable, as “communities, health professionals, and families can work together to create opportunities for kids to eat healthier and get more active.” Some of the strategies that the HHS recommends are nutrition based, such as “keeping fresh fruit within reach” and providing healthier food options at school, and other strategies are focused on activity levels, such as encouraging families to go on an after-dinner walk and incorporating daily physical activity at school.

While I actually applaud the strategies put forth by the HHS to improve kids’ health, I am saddened to see the focus be on body size. Thanks to Michelle Obama, childhood obesity is at the forefront of the American consciousness. Kids are being weighed and measured at school and then later sent home with a health report card telling them whether they are at a “healthy” body mass index (BMI) or are in the “overweight” or “obese” categories. Even though the medical community as a whole willingly acknowledges that the BMI is woefully flawed as an indicator of health status, it still condones its use in determining the health of our kids. Time and time again, studies have shown that behaviors rather than weight are a better determinant of health, but unfortunately, this is not being reflected in current policy.

My greatest concern is the effect that focusing on childhood obesity could be setting up kids to develop eating disorders (EDs). I cannot tell you how many preteens who have stepped into my office had been sent home with their BMI report card and then developed either extremely disordered eating or an actual diagnosable ED. What often happens is that the parents become alarmed at their child’s negative BMI report and will start to impose harsh diet restrictions and exercise ultimatums. I had one patient whose father promised her and her sister iPads if they both lost weight. Not only would he limit their access to “junk” food, he would make them run laps around their neighborhood after dinner every night. As a result of this, the patient developed a very disordered relationship with food and her body. This story is not unique, unfortunately. I have heard it too many times to count.

So, I have a few issues with the HHS’s focus on obesity. First of all, I don’t believe that we should have schools be weighing and measuring kids and sending them home with a BMI report card. Instead, the child’s pediatrician and parents should be the gatekeepers of the child’s health. Every child has their own unique growth charts – some trend on the higher end of weight for height, while others trend on the lower end of the chart. In other words, some kids are just meant to be in bigger bodies, while others are meant to be in smaller bodies. These body sizes do not tell us anything about the child’s health unless there are major changes in either direction. For instance, one would expect a child trending on the 85th percentile to stay at that percentile. If there was a sharp drop to the 50th percentile, that would be cause for concern. Similarly, if a child was trending on the 50th percentile and then jumped up to the 90th percentile, that should also be looked at. One body type is not inherently healthier than the other – every body is unique.

In addition, I think it is so important to not speak negatively about a child’s weight. Kids are like sponges, and they pick up on everything. Talking with one’s child about how their body works and teaching them how to take care of it is one thing, but telling a child that they are too big and need to lose weight is extremely damaging and can set the child up for years of negative body image and a life of disordered eating. Many EDs start when a well-meaning parent tries to teach their child to diet and use exercise to burn calories. In fact, there are a number of studies that show that when children are put on restricted diets, they will often end up being heavier adults.

Also, I think that if a parent has concerns about his or her child’s weight, they should talk with their child’s pediatrician separately (i.e., not with the child in the room). Instead of telling the parent that their child simply needs to lose weight, it would be wonderful if pediatricians did not just make an assumption based solely on the child’s weight that the child is engaging in unhealthy behaviors. If it is determined that the child is in fact not practicing healthy lifestyle behaviors, it would be best if the doctor just focused on helping the child develop these healthy habits (perhaps by referring them to a registered dietitian or other health care provider) and measure the child’s progress by their weight.

Given that, I don’t think that National Childhood Obesity Awareness Month is helpful at all in helping our kids lead healthier lives. By teaching them that weight is synonymous with health, we are doing them a major disservice. Perhaps September could instead be called National Healthy Habits Awareness Month? Just a thought.

Busted

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Football player Rob Ninkovich announced today that the league has suspended him for four games for taking a banned substance. Ninkovich explained, “Few things are more important to me than my name and reputation. This might call that into question for some, which has me heartbroken. I don’t want to cut any corners. I want to do things the right way, with high integrity, and that’s what I have always wanted to stand for.”

He continued, “Any supplement I’ve ever used was bought at a store. I was unaware something I bought had a substance in it that would give me a positive test because it wasn’t listed [as an ingredient]. One thing I have learned is that if a supplement is not NSF certified there are no regulations that ensure that what is on the label is 100 percent accurate. That is a hard lesson for me to learn at this stage in my career, but I take responsibility for it. It’s a mistake I made and it hurts that I won’t be there for my teammates.”

Patients frequently ask me about supplements, particularly protein powders. Pop culture nutrition is fickle. Not too long ago, we emphasized carbohydrates and feared dietary fat. Today, we are scared of carbohydrates and worship protein. As such, people who are already getting more than enough protein often feel they need even more and turn to a protein supplement.

Protein powders, like other supplements, are largely unregulated. Generally speaking, we have no idea if the contents match the listed ingredients or if the quantities reported on a bottle’s nutrition label are accurate. Back in 2008, I read a study (which I unfortunately cannot find right now) that analyzed actual protein content in various powders and found that most did not contain nearly as much protein as advertised.

Furthermore, as odd as it may initially sound, realize that manufacturers have incentive to add secret ingredients. Competition is fierce; a quick search of GNC.com yielded 512 different protein supplements. Consumers often make their selections based upon the perceived results or testimonials of others. If you are a supplement manufacturer and you want your product to stand out among the rest, to be the one that is perceived as yielding the best results, the one that gets talked about and recommended in the locker room, you may decide it is in your best interest to slip in an unlisted ingredient that produces the desired effect.

Whenever an athlete like Ninkovich gets busted and blames his supplements, the common reaction is to assume they are lying and covering for having purposely taken a performance enhancer. That may indeed be true, but we have to remember that what we often see as an excuse is also a completely plausible explanation.

You may or may not get drug tested the way that many professional athletes do, but the uncertainty of supplement contents can still impact you. Might an ingredient, listed or otherwise, interact with one of your medications, make you nauseous, give you a headache, accelerate your heart rate, or damage your liver? You could have no adverse reactions at all, wind up dead, or anywhere in between. That’s the risk.

If you use a supplement or are considering taking one, think about the potential ramifications, and remember that the lesson Ninkovich apparently learned today is actually an important lesson for us all.

Hold Off On Time-Delayed Eating

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

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

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

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

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

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

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

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

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

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

Wishful Thinking

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Last December, I stumbled upon a very interesting article on the website Ravishly. The piece, entitled “Being Thin Didn’t Make Me Happy, But Being ‘Fat’ Does,” written by Joni Edelman, caught my attention for pretty obvious reasons. In it, Edelman included two pictures of herself, one with the caption “Before” and one “After.” As you might have guessed, her before picture is of her when she was at a much lower weight at the age of 35. The after picture is of her and her family, five years later when Edelman was at a much higher weight. Edelman goes on to describe the extreme measures she took to achieve her “physical hotness” displayed in the first photo, including counting calories obsessively (limiting her calories to 1000 per day), exercising excessively (running 35 miles per week), and overall living a very restrictive lifestyle.

While Edelman concedes that being at this low weight came with some “benefits” such as being able to fit into size 4 clothing and receiving positive attention from men, she says that the amount of effort, sacrifice and mental energy it took to maintain this weight significantly diminished her happiness. She found that the time and energy it took to keep her figure ended up taking away from her relationships, especially with her children, as she was preoccupied with her food and working out.

Realizing that “happiness does not require thinness” and “fatness does not presume sadness,” Edelman stopped her extreme dieting and exercise behaviors. As one would expect, she gained weight, and with medication changes to treat her bipolar depression, she gained even more weight. Despite this, Edelman wrote that she had found a “stillness, a joy, and a peace” that she had never had and that “it’s worth 10 pounds.” The article ended with Edelman telling her readers to “be fat and happy. Be unapologetically fat. Wear a bikini, and mean it. Eat pizza and ice cream and enjoy it. Drink up your life and a bottle of wine, and make no apologies.” It was a refreshing article and one that I imagine took a great deal of courage for her to write. In our fat-shaming, thin-exulting world, it’s rare to hear someone (especially a woman) talking about being both fat and happy.

A few weeks ago, one of my patients forwarded me another piece written by Edelman. Apparently, Edelman has decided to start writing a bi-weekly column entitled “Beyond Before & After,” (BB&A) where she hopes to discuss “living without dieting, fostering self-love and healthful choices made on our own terms. No scales, no calorie counting, no before, no after. Because we’re so much more than that.” Sounds promising, I initially thought to myself.

In the first installment of BB&A, Edelman talks about her blog from last December. How she received so much praise and attention for writing so bravely about something that many woman would be afraid to do – to call themselves “fat” and be okay with it. But then the article takes a turn. Edelman writes that even though she fully believed that she could be fat and happy, something started to shift. She describes instances in which her body started to fail her, such as not being able to sit on the floor without falling because she was not able to bend due to her stomach getting in the way. How she was tired of feeling breathless after walking up 13 stairs and how her weight was making it nearly impossible to heal an injured ankle. All of a sudden, Edelman writes that being fat “stopped working for [her],” and that she wanted to change this by losing weight, that “if being fat doesn’t work for you, you can change, or you can at least give it your best effort.”

Oh dear. I don’t know where to begin with this. First of all, this piece makes me sad. Here was someone who was fighting the good fight, who really seemed to get it: that weight and health and wellbeing are not inextricably linked. That there are plenty of thin people with health problems and plenty of fat people with none. Interestingly, Edelman talks about how she got her blood work done (in addition to numerous other health tests) and surprisingly enough, her labs were nearly impeccable, with a low thyroid as the sole issue that arose. Other than this (and being diagnosed with peri-menopause), Edelman was in excellent health. But, even with this positive information, Edelman is resolved to change her body.

Okay, time for some full disclosure: part of me understands where she is coming from. I am also living in a larger body and there are times that I think to myself, “you know, your knee pain and plantar fasciitis would likely improve if you lost weight.” Biomechanically, I understand that carrying more weight translates to more stress and strain on my body. But, then my rational mind kicks in and reminds me of several facts: 1) There are plenty of thin people with knee pain and plantar fasciitis (just ask nearly all of my slender tennis teammates) 2) There are numerous ways to address these health conditions without losing weight (just ask my podiatrist and my physical therapist) and, most importantly, 3) Permanent intentional weight loss is impossible for 95-98% of those who try to achieve it. So, even if losing weight did improve my issues, no one has found a way to keep the weight off. In fact, most people end up gaining even more weight than they had lost in the first place, resulting in an even higher weight.

The other issue I want to shed light on is Edelman’s admission that she has struggled with an eating disorder (ED) in the past (namely exercise bulimia). Even if she is not actively engaging in restriction and over-exercise, her weight loss goal is simply ill advised. Recovery from an eating disorder is a life-long process and it is completely at odds with purposefully losing weight. You can’t be in recovery and be actively trying to lose weight. They are incompatible. Even Edelman realizes how tricky her endeavor is going to be, admitting that she has already been weighing herself more than once a day and has been drinking copious amounts of water to help her feel full. I will not be surprised to see her get back into an ED mindset if things continue this way.

Listen, I get it. Being fat can be tough in our society, and it’s easy to blame our physical maladies on our body size. But just deciding that being fat isn’t working for you and that you are going to change your body permanently is at best wishful thinking and at worst a very dangerous endeavor. I hope that Ms. Edelman figures this out before it’s too late.

He Said, She Said: My Big Fat Fabulous Life

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In a recent episode, of My Big Fat Fabulous Life, the protagonist visits her alma mater where she gives a talk about body positivity and then fields questions from students. Who knows what really went on in that auditorium, but if we take the video at face value, she did a fine job of responding, especially for a layman who was put on the spot. With time and expertise on our side, we took our own stabs at answering two of the questions that arose.

 

He Said

“The medical community actually agrees that obesity can lead to a shorter life span. Do you think that your No BS [No Body Shame] campaign, which emphasizes feeling confident and beautiful at any size, do you think that that can coexist along with the very real facts that they do cause legitimate health concerns?”

The premise of this question is faulty in a few different ways.

No, the medical community does not agree that obesity can lead to a shorter life span.

Research actually suggests that other factors have a greater impact on mortality than does body size. For example, a 2012 study by Matheson et al. looked at the impacts of consuming five or more fruits and vegetables daily, exercising regularly, consuming alcohol in moderation, and not smoking and found that mortality was virtually identical across all studied body mass index groups when subjects had all four healthy habits. In other words, when it comes to our risk of dying early, behaviors are a better predictor than is body size.

In his 2010 study, Fogelholm found that physically active obese individuals had better cardiovascular and all-cause mortality risk than sedentary “normal weight” people, again suggesting that when it comes to matters of life span, behavior is a more important factor than is body size.

The entire body of research is bigger than just two articles, and of course, not every study reaches the same conclusion, which reinforces how much we still have to learn and underscores how inaccurate claims of universal agreement within the medical community are regarding this complex topic.

Size acceptance and health are two separate issues.

“The mission of the No Body Shame campaign,” according to its website, “is to help every individual overcome the debilitating effects of societal-induced shame. Supporters of No Body Shame have named weight, height, skin color, sexual orientation, gender, different abilities, and specific physical attributes as causes of shame. Whitney believes that when we commit ourselves to living our best lives now, accepting ourselves as we are even if others do not accept us, real changes in confidence and quality of life are not only possible, but imminent.”

Note that nowhere in the mission statement does health appear. No BS is part of the size acceptance movement, which is related to, but not synonymous with, initiatives like Health at Every Size (HAES®) that promote a paradigm shift within the medical community to focus on actual health instead of weight.

In explaining size acceptance, Ragen Chastain writes, “Everybody deserves basic human respect and civil rights and that should never be up to show of hands or vote of any kind. Fat people have a right to exist, there are no other valid opinions about that. Our rights to life, liberty and the pursuit of happiness are not someone else’s to give, they are inalienable. SA [Size Acceptance] activism is not about asking someone to confer rights upon us but rather demanding that they stop trying to keep them from us through an inappropriate use of power.

HAES, on the other hand, can be succinctly encapsulated as a weight-neutral approach to health. The Association for Size Diversity and Health (ASDAH) elaborates by saying, “The framing for a HAES approach comes out of discussions among healthcare workers, consumers, and activists who reject both the use of weight, size, or BMI as proxies for health, and the myth that weight is a choice. The HAES model is an approach to both policy and individual decision-making. It addresses broad forces that support health, such as safe and affordable access. It also helps people find sustainable practices that support individual and community well-being.

While size acceptance and HAES are different concepts, clearly they relate. The situation is more complex than I am about to make it seem, but for the sake of brevity, consider how weight stigma pushes people into weight-loss pursuits that are most likely to worsen their health. If we as a society are more accepting of people of all sizes, we free each other up to instead focus on our actual health.

The implication that feeling unconfident or unbeautiful at certain sizes inspires better health is the exact opposite of what tends to actually happen.

Tomiyama and Mann conducted a study in which they posed two sets of questions to different subject groups. One set of questions was designed to make the subjects aware of weight stigma while the control questions asked about ecofriendly behaviors.

After subjects answered their questions, researchers presented them with a variety of foods and gave them permission to eat whatever and however much they would like. The people who had just responded to questions about weight stigma consumed significantly higher amounts of sugar and calories than those who answered neutral questions.

Their findings mirror our clinical observations and experiences. People often believe that self-dissatisfaction will somehow inspire better health, when in reality the individuals who love and accept themselves as they are tend to be the ones motivated to take better care of themselves.

Correlation is not synonymous with causation.

The questioner ended her inquiry with, “the very real facts that they do cause legitimate health concerns.” The context suggests that she misspoke when she used the word “they” and was actually referring to obesity.

If that presumption is indeed correct, then she is confusing correlation and causation. Earlier this month, I watched a fireworks display one evening and then a parade the next morning. Did the fireworks cause the parade, or did these events occur in close proximity to each other due to another factor, say, Independence Day?

Similarly, when we consider the diseases linked to obesity, we must remember that correlation does not equal causation. The link, in other words, might not be a causal relationship, but rather an association due to other factors. Many examples exist, but for the sake of brevity, consider just one: stress. Cardiovascular disease, which is often blamed on obesity, is also associated with life stress.

If you are not obese yourself, do your best to put yourself in those shoes for a moment: You live in a society where the government has declared war on your body size; where fat hate and bullying are prevalent online and in real life; where you might fear going to the doctor because you are more likely to receive a judgmental directive to lose weight rather than an actual evidence-based medical intervention; where commercials, memes, advertisements, talk at the gym, the grocery store, and over the dinner table hammer at you repeatedly throughout the day, every single day, that something is wrong with you and it is your fault. Tell me, how is your stress level?

 

She Said

“My father passed away this past April. He was severely overweight, he was diabetic, and he was an avoider, right. Do you think there is an ethical concern in folks who view you as a health and fitness expert or at least a public figure and use that body positivity message as an excuse to avoid actually addressing their real health concerns?”

While the second sentence of this audience member’s question is not a question at all, I think it needs to be addressed. Although he didn’t specifically say so, this statement reads as though the questioner believes that his father’s weight was to blame for the development of his type 2 diabetes (T2D). As we have discussed numerous times before, weight and health are two very different things and that while being “overweight” or “obese” might be correlated with certain health conditions, such as diabetes, there is no evidence that being “overweight” or “obese” causes these conditions.

In a 2012 interview for the Health at Every Size blog, author Linda Bacon explains, “while it’s true that the majority of people with T2D are in the BMI categories of ‘overweight’ or ‘obese,’ that’s at least in part because the insulin resistance that underlies most cases of T2D often causes people to gain weight. In fact, weight gain may actually be an early symptom—rather than a primary cause—of the path toward diabetes.” In addition, Bacon cites a “review of controlled weight-loss studies involving people with T2D” which showed that while “overweight” or “obese” individuals with T2D had initial improvements in their blood sugar levels with weight loss, those levels eventually returned to baseline within 6 to 18 months, even for those few individuals who had managed to keep the weight off.

I also think it is important to look at the way that the questioner described his dad: as an “avoider.” That tells me that this man believes that his father did not take care of himself to the extent he could have in order to have prevented his untimely death; that if his father had not “avoided” his health issues by presumably eating better and losing weight, he might still be here today. That seems like a very serious assumption. Sometimes even when people take all the right steps in dealing with their health condition, they will still pass away. We all like to think that if we eat perfectly, don’t smoke, don’t drink, and do all the “right things” (i.e., healthy life behaviors), we will live forever. Unfortunately, none of us is immortal.

Now to address the actual question that was asked. I find this question problematic for a couple of reasons. First, I don’t think that Whitney (the protagonist of MBFFL) has ever tried to portray herself as a “health and fitness expert.” Over the first 3 seasons, she has consulted with a registered dietitian who practices Health at Every Size® (HAES®), has seen a cardiologist, and has been working with a personal trainer in addition to other health professionals. She herself admits that she struggles with the health and fitness part of her life, particularly in that she battled an eating disorder for much of her teens and twenties. She has never presented herself as an expert in nutrition, fitness, or medicine.

The second reason I find the question problematic is that the questioner assumes that the message of body positivity is being used as an excuse for people of size to avoid dealing with their health issues. This is simply untrue. Body positivity is about seeing all bodies as “good” bodies, that no one body type is the “ideal,” regardless of what our society (particularly the media) likes to tell us. In other words, the body positivity movement says “there is no wrong way to have a body.” It also recognizes that “good health” is not a requirement to have a body and that sometimes (due to circumstances outside of one’s control) our bodies might not be healthy. This does not mean, however, that these bodies are any less good.

At the end of the day, I think the best way to think about this question is through the lens of the “Underpants Rule,” coined by the brilliant blogger Ragen Chastain of Dances with Fat. Ragen defines the rule as such: “everyone is the boss of their own underpants so you get to choose for you and other people get to choose from them and it’s not your job to tell other people what to do.” This means that others do not have a right to tell you how you should take care of your body and vice versa. Whitney has never told her viewers (at least to my knowledge) how they should be treating their health conditions – she is only focusing on her own body and health issues.

Body positivity does not assume that everyone is actively trying to be living their healthiest life. It is more about helping people realize that skinny bodies are not the only bodies that are worthy or beautiful. Yes, some individuals might show love for their bodies by trying to take care of them by eating a varied, nutritious diet, being physically active in an enjoyable way, getting enough sleep, and managing stress. But not everyone is able to engage in all of these behaviors. The body positivity movement says that even if one is not in the best of health, their body is still valuable.

He Said, She Said: Parents

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WorldEDDay

He Said

June 2nd was World Eating Disorders Action Day, which was an important occasion that helped to cast desperately needed light on these conditions that are so common, yet receive so little attention.

Many of our colleagues shared articles, blog posts, and memes on social media to commemorate the day. One particular meme caught my attention because it read in part, “Families are not to blame, and can be the patients’ and providers’ best allies in treatment.”

To be candid, that statement is only partially true. On one hand, eating disorders can certainly arise in the midst of even the most loving and supportive family dynamics. On the other hand, environment is an important factor in the development of eating disorders, and this broad term that encompasses television, social media, print media, teachers, friends, coaches, co-workers, and many other influences also includes family.

Neither Joanne nor myself is here to pass judgment on anybody. Parenting is hard work, and all of us, parents and otherwise, make mistakes sometimes despite our best intentions. If we are to help families become the supportive allies that the meme correctly states they can be, then we must acknowledge the reality that even well-meaning and loving parents sometimes inadvertently contribute to the problem.

This month, Joanne and I discuss some of the most common mistakes parents make that can promote or exacerbate an eating disorder or otherwise hinder their child’s nutrition care, and we suggest alternative behaviors that can be more helpful. Joanne tackles the behaviors most related to eating disorders while I address others that I see in my side of the practice, although overlap certainly exists between the two.

Mistake 1: Modeling disordered behavior

“I can’t do moderation,” one of my patients insisted. She was 12 years old. With both of her parents out of the room, she explained to me how her parents oscillate between restriction and overconsumption. The former might take the shape of cleanses, clearing the house of “junk food,” enrolling in weight-loss programs, or other similar actions, while the latter might manifest itself through binges, lamenting their eating behaviors, or expressing concerns about a food “addiction” or feeling out of control.

The patient in question was well aware when one of her parents was about to transition from one state to another. “You cracked the seal!” her mother reportedly exclaims to her father (or vice versa) when a “bad” food is brought into the house. Because this is the behavior modeled in my patient’s household, no wonder she similarly feels, at such a young age, already destined for and incapable of anything beyond an all-or-nothing relationship with food as well.

Improvement: Model a healthy relationship with food

Children often learn through observation. Family meals in particular are an excellent time for parents to model their healthy relationship with food. Serve and consume a wide variety of foods. Destroy the good/bad food dichotomy by incorporating “bad” foods and showing that one is neither guilty for having them nor virtuous for sticking solely to “good” foods.

Similarly, keep a wide variety of foods in the house, as attempts to restrict the food supply typically backfire sooner or later. Children are bound to encounter “bad” food at friends’ houses, camp, and other environments, so better to help them build a healthy relationship with these foods early in life before they grow into young adults who do not know how to handle the newfound freedom that accompanies all-you-can-eat college dining halls.

In order to model a healthy relationship with food, parents must first of all have one. Be candid with yourself and realize that the best way to help your child might be to recognize and seek help and support for your own eating issues.

Mistake 2: Putting too much responsibility on the child

Encouraging autonomy and empowering children have their upsides, but parents sometimes take these actions too far. They step so far back that children are left without the parental support that they need to succeed. Parents might leave their children alone with us for more time than would be ideal, decline invitations to meet with us without the children or to check in with us between sessions, opt not to reinforce at home the ideas we discuss in session, or fail to implement action steps that necessitate parental involvement.

Improvement: Work together as a team

Just as children of all ages look to their parents for a variety of resources, everything from physical needs to unconditional love, they need similar help with their nutrition. Children have their own feeding responsibilities, but so do parents. In order to suss out who is responsible for what, parents must actively participate in the process. Initially, parents may not see eye to eye with us or have questions or concerns about our approach, and these thoughts are best expressed in private so as not to confuse the child with conflicting paradigms. In short, working together as a team tends to yield the most fruitful results.

Mistake 3: Assuming their children can lose weight because they did it themselves

Many of the children at our practice have parents who are high achievers. Through hard work, discipline, sacrifice, and other life choices and factors, they have reached the pinnacle of their respective fields. Some of these parents have applied these same traits to their own weight-loss endeavors with similar results. They assume that if their children take a similar path, they will reach the same outcome.

Improvement: Differentiate between typical and atypical results

If you have lost weight and kept it off, recognize that you are the exception, not the rule. Approximately 95% of people who attempt to lose weight will regain it one to five years down the road, and roughly 60% of these individuals will end up heavier than they were at baseline. Weight regain is common even if someone maintains the behaviors that promoted the weight loss in the first place.

Contrary to popular myth, our weight is largely out of our hands. The calories-in-versus-calories-out paradigm is a gross oversimplification of the complexities affecting weight regulation. While we might be able to manipulate our body size through behavior changes for a short while, biological mechanisms promoting weight regain almost always win out in the end.

Even genetics and behaviors together do not tell the whole story. For every Griffey or Boone family, we have hundreds of major league ballplayers whose offspring will never make it in the pros. Set aside the notion that what worked for parents will work for a child, and accept that your child may never lose weight and keep it off no matter what he or she does.

Mistake 4: Encouraging weight loss

A desire to lose weight leads to dieting, which is a predictor for eating disorders, worse health, and ultimate weight gain. Parents may understand the dangers and futility of dieting and instead encourage “lifestyle change.” Unbeknownst to them, the behaviors they have in mind, such as restricting calories or certain food groups, keeping a food journal, weighing or measuring portions, or staving off hunger by filling up on liquids or low-calorie foods, are still tricks of the dieting trade. Different packaging, but same contents.

Improvement: Promote size acceptance

Weight stigma is real and widespread. Children encounter it on the playground, on television, on social media, in the classroom, and maybe even at the pediatrician’s office, but they do not have to face it at home. Promote size acceptance and discuss the stigma they inevitably bump into as they move about the world. An additional and important lesson: Teach them not to contribute to said stigma.

Mistake 5: Talking about “health” as a euphemism for “weight”

Sometimes parents have a sense of the dangers associated with focusing on a child’s weight, so they substitute in the word “health” instead. Children are perceptive, however, and they learn about our cultural obsession with weight and size at an early age. When their parents say, “I just want you to be healthy,” they interpret this in context and hear, “I just want you to lose weight.” When they start talking to the big kid in the family about “health” and bring him to a dietitian while his skinnier siblings receive no such treatment, trust me, he knows exactly what is going on.

Improvement: Recognize that health and weight are not synonymous

Health and weight are not nearly as synonymous as we have been led to believe. Studies have shown that weight loss does not automatically lead to better health, and other research that controlled for behaviors found that health risks between groups of people of different body weights were nearly identical when engaging in similar behaviors. If health itself is indeed the priority, then apply it to everyone in the family, regardless of body size.

 

She Said

June 2nd was World Eating Disorders Action Day, during which numerous organizations and activists all over the world brought to light the prevalence of eating disorders (ED) and the need for comprehensive treatment. Jonah and I noticed a meme that was circulating on that day which outlined nine facts about EDs. While overall I felt like the meme was accurate and could be quite helpful for those unfamiliar with EDs, I felt like one of the “truths” was not completely accurate. This “truth” states, “Families are not to blame, and can be the patients’ and providers’ best allies in treatment.” My issue does not lie with the second part of the sentence, as I fully believe that parents can be wonderful allies in helping someone recover from an ED. But I do not agree with the statement that families are not to blame.

Let me be clear: I am not saying that it is solely the parents’ fault if their child develops an ED. But absolving parents of any blame doesn’t ring true to me.  As in most diseases, genetics play a large role as does environment. One way of thinking about it is this saying: “Genetics load the gun, but environment pulls the trigger.” Well, parents are part of the child’s environment, and therefore they can contribute (even unwittingly) to the development of their child’s ED.

99% of the time, parents are acting out of love for their child. They don’t want their child to suffer and only hope that he or she will be happy and healthy. But even with the best intentions, sometimes parents (and other family members) can inadvertently trigger an ED in a genetically predisposed patient. The following are some examples of how this can occur:

Example #1: The parent speaks negatively about his or her own body.

This might be surprising to some people, but children of parents who speak disparagingly about their own bodies (i.e., not their child’s body) are more likely to develop issues with eating and body image. I’ve had numerous patients whose parents only tell the patient how beautiful/handsome/perfect he or she is, or that there is nothing wrong with the child’s body. However, oftentimes the child will overhear their parent complaining about their own “love handles,” saggy body parts, or “unsightly bulges,” and even though these comments aren’t directed at the child, he or she learns to internalize these messages and can start to believe that his or her body is “wrong” too. The best way to prevent this from happening is for parents to avoid negatively talking about their own bodies, especially in the presence of their child. All bodies are good bodies, and stressing this message can help kids develop a more positive body image.

Example #2: The parent puts too much responsibility on the child and does not take an active role in his or her ED recovery.

Sometimes I encounter parents who want to take a step back from their child’s ED, as they believe that the child should be in charge of his or her recovery. While I agree that the patient needs to take an active role, most kids are dependent on their parents for food, as parents are the ones who go grocery shopping and who do the meal prep and planning. A child who is dealing with an ED cannot be counted on to feed himself or herself appropriately. Very few kids with EDs take the initiative to prepare a snack or meal for themselves. I had one patient that often would skip meals and snacks because she knew that her parents weren’t watching her. My advice would be that parents need to take an active role in their child’s ED recovery, especially if that child is a younger teenager. This means that parents might need to supervise meals and snacks, make sure that there are ample and appropriate food choices in the house, and hold the child accountable for food eaten outside of the house. Regarding the latter, signs may suggest that a child is not following her meal plan while at school, for example. In such instances, parents have the responsibility to arrange for a teacher or school nurse to supervise the child’s eating to ensure compliance with the meal plan.

Example #3: The parent encourages their child to lose weight.

This is a tough one. In our fatphobic and fearmongering culture, being overweight or obese is seen as a terrible fate. With the help of Michelle Obama, every parent is vigilant about their child becoming a part of the “childhood obesity epidemic.” Even if a parent feels like their child is “fine,” pediatricians can scare parents into seeing their child’s weight as a ticking time bomb. I’ve had too many patients to count whose parents bring them in because their doctor wants the child to lose weight. In some cases, these kids are encouraged to go on diets, and they receive praise for every pound lost. I had one patient in particular whose parents promised her a new iPad if she lost a certain amount of weight. Obviously, I feel that encouraging one’s child to lose weight is very problematic. Study after study has shown that kids who start dieting from an early age are actually more likely to become overweight or obese in adulthood. In other words, the end result is the exact opposite of what these parents are hoping for. My best advice is to stop focusing on your child’s weight. Instead, focus on his or her health, as we know that health and weight are not necessarily synonymous. Also, I would recommend talking with the child’s pediatrician (without the child present) to discuss taking the focus off the child’s weight, as negative messages about the child’s weight can lead to a preoccupation with food and even development of an ED.

Thus, while I really agree overall with the “truths” outlined by the meme, I would modify #2 to say that family dynamics can play a role in the development of an ED. While it is true that parents are not solely to blame for their child developing an ED, they can use some of the above strategies to make it less likely that their child will go down that treacherous path.