What’s the deal with that egg study?

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

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

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

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

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

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

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

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

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

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

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

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

Intuitive Eating and Infants

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

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

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

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

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

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

Evelyn

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

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

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

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

My three favorite memories of my grandmother are as follows:

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

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

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

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

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

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

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

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

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

The Natural Purple Pill?

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

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

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

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

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

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

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

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

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

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

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

Dietetics Within the Health at Every Size (HAES) Framework

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“Just tell me what to eat”

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

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

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

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

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

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

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

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

Skeletons in the Literal Closet

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We have put out a newsletter every month since we first began writing them in May 2013, but this month’s issue almost did not happen. Between fatherhood and the chaos of our practice’s move, I had little time to write this month. Taking advantage of any windows I did have, I began to write a feature only to realize towards the end that I had already written about more or less the same subject last year. Ugh.

Just when I was about to concede that this month’s newsletter was a lost cause, I opened our office closet in the midst of packing and spotted some of my proverbial skeletons, relics from when I practiced using a very different approach than I do now, and I realized I had found this month’s newsletter topic.

Because some of our readership is comprised of former patients who worked with me when Joanne and I first established our practice (and some readers go back even further to when I was working elsewhere), they have witnessed the evolution of my work firsthand, whereas other readers probably have no idea what I am talking about and figure I always worked the way I do now. How I wish that were the case. The truth – the embarrassing truth – is that I used to be very much part of the problem.

A small cardboard box on the top shelf contained a squishy, slimy, yellow rectangle: a model of a pound of body fat. One of my colleagues gave it to me back in 2010, I think it was, with the idea that seeing the “fat” would motivate patients to lose some of their own. The connotation was clearly negative, as reinforced by the written description that came packaged with the model, and I remember feeling uneasy about using it with my patients. Even though I was practicing from a weight-centered model of care at the time, my counseling instincts suggested that scare tactics and shame were unlikely to yield any positive results. Regrettably, I did show the model to a handful of people, and the experience reinforced that my intuition was on the right track. Back in the box it went, and there it stayed until recently taking up residence in the dumpster behind our office building.

The most glaring skeletons were scattered over the closet floor: scales. Over the years, we accumulated quite the collection, including two basic home models, a medical-grade wireless body composition analyzer, and an old-fashioned physician beam scale. My schooling and internship were largely weight focused, but to be fair and completely honest, some weight-neutral lessons did creep in, such as this article that came up in my nutrition assessment course, but they were easily drowned out by the tsunami of weight-focused messages that echoed my own preconceived notions about body size and shape.

Once I began practicing, I discovered that helping people lose weight and keep it off was not nearly as easy as most of my schooling suggested it would be. My patients nervously got on the scale at their follow-up visits, but they had no idea that inside I was just as anxious, for I felt that lack of results meant that I was a bad dietitian. To be candid, I was a bad dietitian, but my problem had nothing to do with the dearth of lasting weight loss among my patient population and everything to do with my approach that focused on such numbers in the first place. Five or six years ago, I began talking with more seasoned colleagues, such as Heidi Schauster and Ellen Glovsky, who opened my eyes to the reality that weight-focused approaches to care almost never work. Shortly thereafter, I stopped weighing my patients or testing their body composition. Pitching our scales into the dumpster last week was as satisfying as it was symbolic of how my approach to care changed over our time in Wellesley.

This October, I will be speaking at Massachusetts General Hospital about weight stigma in healthcare settings, and one of the specific topics the course directors have asked me to address is my transition from a weight-focused paradigm to a weight-neutral approach to nutrition counseling. Other dietitians, as well as nurses, physical therapists, and other healthcare practitioners, will be in the audience, and it is important for them to know that we all screw up sometimes. We can come to see our mistakes, own them, learn from them, and change course. Our patient care improves, which is the bottom line.

My learning continues. As Joanne and I unpack and get settled into our Needham office, I think about the artifacts from today that I will find hidden away in our file cabinets, desk drawers, and closets upon retirement decades from now. Hopefully, I will not look back on them with embarrassment similar to what I felt upon opening the Wellesley closet, but let’s be honest, there is a lot of professional education and growth still to come.

Soolman Nutrition is moving!

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

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

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

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

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

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

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

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

Cause and Effect

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The Academy of Nutrition and Dietetics releases a daily Nutrition and Dietetics SmartBrief, which contains summaries of and links to recently released health and nutrition articles. Earlier this month, a headline in a recent issue read, “Too much sitting increases risk of early death, study says.”

The problem is that no, that is not what the study says. In fact, the HealthDay article that the SmartBrief links to states, “The study couldn’t prove cause and effect . . .” and a couple of paragraphs later, the article continues, “It’s not clear why prolonged sitting is unhealthy, Patel [lead researcher, Dr. Alpa Patel] said. It’s possible that people who spend a lot of time on the couch also have other unhealthy behaviors, such as excess snacking, she suggested.”

Okay, let’s back up a moment. First, the author who wrote the SmartBrief’s headline misrepresented the study’s findings by implying causation, and second, Dr. Patel herself seemed to disregard the limitations of her own research by labeling sitting as “unhealthy” based on an association.

This was not just a SmartBrief problem. Other news outlets picked up the story and similarly misled consumers. For example, the headline on NBC News read, “Here’s more evidence sitting too much can kill you,” with the subheading, “Sitting more than six hour [sic] a day during your free time raises the risk of early death by 19 percent.” No, that is not what the research found at all, but such sensationalism probably draws more clicks than a mundane – but more accurate – headline.

We see similarly misleading language when it comes to reporting on the research that investigates the relationship between weight and health. Headlines summarizing these pieces oftentimes imply a causal relationship between increased body weight and morbidity. Remember, however, that when researchers set out to investigate the consequences of obesity, they are also studying the impacts of weight stigma, dieting, weight cycling, socioeconomic disparity, healthcare discrepancies, and everything else that tends to come packaged with the experience of having a bigger body in today’s world.

While increased adipose tissue in and of itself could be a causal factor for certain health conditions, similar to how having fair skin increases one’s skin cancer risk, establishing a causal relationship is extremely difficult given the confounding variables. To assume causation because of correlation is premature at best, and at worst, it could be completely wrong.

Next time you see a headline that implies causation, remember that said headline might be more sensational than factual, as the actual research behind it is probably more complex and nuanced than can be accurately distilled into a single line of text or a sound bite.

Thoughts on Body Image and Pregnancy

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I want to preface this installment of pregnancy thoughts with this: the biggest lesson I have learned regarding pregnancy and body is that not only is every woman’s body different, but every pregnancy is different for each and every woman. What I am writing about in this piece is my own personal experiences, and it is not meant to be generalized to other women’s experiences. There is no wrong way to have a pregnancy and/or a pregnant body!

Thoughts on Body Image and Pregnancy

Some of the earliest advice I got from female friends and family members when they found out about our news was around making sure that I did not gain “too much weight” over the course of my pregnancy. Of course, I feel that these sentiments are rooted in fat phobia and diet culture, but many women also told me that they themselves ended up gaining “huge” amounts of weight during their pregnancies (much more than the medically recommended amount), which led to complications. While I am not a doctor and do not know the intricacies of these women’s pregnancies, part of me wonders if perhaps this “extra” weight gain might have resulted from the rebound bingeing I described in the previous newsletter feature, although it could just be how their bodies responded to pregnancy.

The other thing I have wondered in these situations is if these women give this advice to all pregnant ladies or just fat ones. Given that I have been living in a larger body for a number of years now, I am curious to know if these women are worried about potential medical complications for my pregnancy or, instead, how much fatter I will get. I have not asked these women questions about their intentions, but it definitely has crossed my mind.

Being a fat pregnant person is an interesting experience. For me, my baby belly did not become all that visible until relatively recently. This is partly due to the fact that I tend to dress in loose clothing (that is just my style), so my baggy sweaters and sweatshirts do camouflage my bump. But I also think that starting out as a fat woman, I was not going to have the stereotypical pregnant body that we all see on TV and in the movies. When I used to envision a pregnant woman, I would think of a slender woman who is “nothing but bump,” i.e., lean all over except for the “perfect” round tummy. I feel that we rarely see representations of fat pregnant women on TV or in movies, so that what the “typical” pregnant body looks like has been skewed for many of us. I was big before my pregnancy, and now I just look bigger in my belly area; if you did not know I was pregnant, you might not assume as much.

This “untypical” pregnant body has its pros and cons. On the one hand, I do not like to have a lot of attention focused on me, so not appearing obviously pregnant has helped me fly under the radar a lot, which I appreciate most of the time. One of my good tennis friends told me that she had a tough time during her pregnancies as she is a very private person, and her protruding baby belly made her quite conspicuous. She described how people on the street would approach her and touch her belly and give her a lot of attention that made her uncomfortable. I am sure she would have preferred to have had a bit more camouflage at the time!

But there are also times when I wish that it were more obvious that I am pregnant. In our society, pregnant women are (for the most part) treated lovingly and with respect. If a pregnant woman gets on the T, people will give up their seat for her. Her baby belly garners smiles and warm greetings. I am missing out on that as my baby bump is not prominent, and sometimes that makes me sad. When Jonah and I went on our “babymoon” vacation in March, no one could tell I was pregnant. They knew we were celebrating something, so they assumed it was our honeymoon, and as such, they kept on trying to give us champagne! I was able to laugh at it at the time, but there was also something a bit disappointing about not having my pregnancy celebrated by others.

Another thing that has been super interesting to notice is how friends and family have commented on my pregnant body. While all of the comments have been positive in nature, it also makes me feel uncomfortable when people comment on my body at all. On many occasions, these friends and family members have said, “Wow, I can’t even tell that you’re pregnant!” or “Good for you for not gaining too much weight!” A few weeks ago, the tennis pro at my club actually said, “You look great – you look like you’ve lost weight!” I know he was trying to be nice, but his comment implied that losing weight would be an improvement for me (as in my pre-pregnancy body was flawed). Never mind that pregnant women are indeed supposed to gain weight over the course of their pregnancies; so any weight loss would not be healthy during this time. These types of comments are fat phobic in nature and reinforce the idea that it is okay to comment on others’ bodies. People, please stop doing this! If you must, saying something like “You look great – how are you feeling?” is a much better sentiment to express rather than commenting on a woman’s specific body changes.

I feel like my pregnancy has given me a new appreciation for my body. I had thought that being “advanced maternal age” and fat would have not only made conceiving nearly impossible, but that my pregnancy would be rife with complications. Incredibly (knock on wood!), everything has been going well! I hesitate to write this, but honestly, being pregnant has been much easier than I thought it would be. Aside from some tooth/gum pain (hello, root canal!), hot flashes (sweating up a storm), and fatigue, I have had very few negative pregnancy symptoms. Of course, this could all change in the final month, but for now, I am amazed that my “old” and fat body is handling pregnancy so well. When I think about the fact that I am actually growing a tiny human right now, it seriously boggles my mind! It truly is incredible!

I am sure that my thoughts about my body will change once I deliver and continue to evolve after the birth and as the years go on. I hope to impart to my daughter the idea that our bodies are truly amazing and are capable of so many wonderful things and that appreciating what our bodies do for us on a daily basis is one of the cornerstones to a happy life.