Weight Stigma in Healthcare Harms Us All

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The following is a guest blog written by Deirdre, who has given us permission to use her real name.

All my life, I’ve been sick. I can remember being five years old and waking up in the morning sobbing because my eyes were swollen shut, I could not breathe, I was always tired, and had severe skin conditions and rashes all the time. I had to go on nasal sprays, steroids, oral allergy medicines, and eye drops almost year-round from that age. Around the age of 14, I started to present with vomiting up bile every single solitary morning before proceeding with my day. Despite complaining to doctors all my life about all these things, I was ALWAYS considered healthy. The number one indicator for doctors? I was thin. I always had a “healthy” BMI, and all my bloodwork looked good, so nobody ever took me seriously.

Fast forward another decade. At this point, my body was so inflamed from consuming gluten – a protein which I later found out I was severely allergic to all along – that I had gained a significant amount of weight. I was 24 years old at this point, vomiting and having diarrhea after every single meal, suffering with mental illness (depression and anxiety, some from trauma but also largely because I *never* felt well and had no choice but to press on), smoking cigarettes constantly to suppress my appetite, abusing Adderall to suppress my appetite, exercising excessively (3-5 mile runs, 10 on weekends, and 2-hour workouts daily). Doctors still would not listen to me.

When I was thin, my health complaints were ignored because I was thin. When I was big, my health complaints were ignored because I was big. This is how weight stigma harms people of all sizes. When doctors are trained to view the BMI as such a strong indicator of our health, they tend to miss out on treating the whole patient and the concerns they are actually presenting. In this way, fatphobia continues to dominate our medical fields in the most insidious ways, regardless of a patient’s size.

When I was younger, I felt like my only sustainable solution was to put restrictions on my eating. I felt like I needed to do everything in my power to just not really eat. The only thing that ever felt good to me was mint chocolate chip ice cream. It was the one food that never made me sick. I ate a pint of it nightly, then would feel guilty, throw up the next morning involuntarily, feel good about that because I was disordered in my eating habits by then, and the cycle of “weight management” continued to wreak havoc on my life and destroy my gut health, self-esteem, and brain chemistry.

At 25, I was accepted to my dream graduate school for my health degree, and thus I was always in Boston. This meant finally seeking out primary care at Fenway Health and getting a fat-positive, conscious, and compassionate doctor for the first time in my life. Dr. Karen Kelly literally saved my life, as I know I would have attempted suicide that year if I had not met her. I was at my wit’s end.

Karen’s team allowed me to face away from the scale when they took my weight. I told Karen all the symptoms I’ve always had. She referred me to an incredible gastroenterologist who finally listened to me and tested me for a bunch of autoimmune gastroenterological diseases.

Notice that only now, because I finally was seeing a fat-positive doctor, was my weight looked past in order for me to receive the care I truly needed. My current health care team, including Karen, is amazing. It is a shame that all the doctors I ever saw prior assumed that being thin meant I was healthy. That mentality destroys a doctor’s ability to see clearly, and my chronic autoimmune disease was completely missed for 25 years as a result. If my celiac disease had been caught sooner, it could have meant avoiding severe damage to my organs, and possibly even reduced my chances of long-term health implications. Now I have to live with whatever damage has been done.

More and more public health research is finally showing that fat people can be healthier than thin people. More and more people are catching on that the BMI as a marker of health is a limited, archaic, outdated, weak, inaccurate, and frankly incredibly lazy way to approach medicine. It is a way for doctors to not do their jobs. All doctors should first and foremost be researchers and scientists listening, looking, and hypothesizing with open minds. I am almost the heaviest I have ever been now, yet my cholesterol, blood pressure, oxygen, etc., are all fantastic.

The concept of weight management is a barbaric and inhumane way for any doctor to practice. One hundred years from now, we will look back at the ways we tried to force mutilation on humans through diets and bariatric surgeries and see the oppressive reality of that kind of hatred of fatness. Doctors that focus on “weight management” and miss what is really going on need to start being held accountable – sued and fired by their patients.

I think that numbers are detrimental, and so is excessive monitoring of size and shape. We came here to live in these sacks of skin as vessels for our non-physical selves, our souls, and nothing more. The BMI is bullshit and was invented by an astronomer in the 1800s who only used white Anglo-Saxon males in his sample size. BMI does not account for muscle mass, bone density, or genetics. It does not leave room for all the boobs and butts and hips our bodies create to cushion us or to grow or feed our babies.

Someday I will have chapters in a book titled “the BMI is racist,” and “the BMI is sexist.” Once I am a doctor or nurse practitioner, I will create a new tool for epidemiologists to test that will actually be inclusive of all sexes, genders, races, etc., without poisoning our minds with self-doubt and self-mutilation.

If I had unbiased doctors all my life, I may have been diagnosed with celiac disease much earlier on and could have potentially saved myself from having cancer or infertility someday. I hope to live a long life and to have children and grandchildren, and I hope to leave them in a world with less weight stigma and more active listening, especially in the field of medicine.

Randomly Targeted

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One of the best books that I have read for professional purposes is Aubrey Gordon’s “What We Don’t Talk About When We Talk About Fat.” Although I have listened to countless patients detail what it is like to have a large body in our fatphobic society, Aubrey’s book helped me to grasp more deeply the contrast between weight stigma and thin privilege.

Some of Aubrey’s stories are wild enough to strain credulity, such as a stranger approaching her in a grocery store and taking food out of her shopping cart without permission due to supposed concern for the author’s health, yet I believe her. A couple of years ago, a Black friend of mine explained to me that Blacks have been complaining about police brutality for decades, but it took the widespread prevalence of cellphone cameras and their resulting videos to convince white folks that the problem is real. His words hit me hard, I learned from them, and I do not need to see video of someone stealing fruit from Aubrey’s cart to believe that this happened to her.

The crux of the book’s fourth chapter, “On Concern and Choice,” is that some people express concern about someone’s weight for supposed health reasons, in part because they believe body size to be a choice – which, for the most part, it is not – something that one can manipulate if convinced that their current size is a problem. Furthermore, their expressed concern is really not about the person to whom they are talking, but rather an indication of the fears they have about their own bodies. In other words, if we acknowledge that body size is largely out of our control, then we also have to face the reality that our own bodies might change in ways that we do not want them to despite our best efforts to keep them the same. That prospect scares the crap out of many people, who find it easier to pretend we have more control than we really do.

This chapter resonated because it hearkened back to the allegations people have directed at me upon learning that I used to have a spinal tumor. Surely you have a family history of such issues, they insist. No. You grew up under high-voltage transmission lines. Wrong again. You overdid it in the weight room. Eye roll. The list goes on. As each assertion is met with a negative response, the concern on their face grows. It took me a long time to figure out what that expression is about, but now I understand that when the ideas that the tumor’s cause was my own doing or something unique to my circumstances are struck down, people then realize that the condition can develop in anyone’s body – most notably their own.

Humans, we are a funny bunch. Our antennae go up a bit higher when we feel like something might affect us rather than just other people, do they not? Think about horrible stories we read about violent home invasions in our community. While the crimes and our thoughts for the victims may be similar either way, contrast how you feel when an article concludes, “The police say the parties were known to each other,” versus, “The police believe the victims were randomly targeted.”

Outer Limits

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A little over six years ago, I wrote a blog entry in which I attempted to rebut the notion that discussing topics other than food in our sessions somehow qualifies as psychology. In reference to intuitive eating, I wrote, “What does it say about how disconnected our culture teaches us to be from our internal signals regarding eating that an approach that encourages us to pay attention to said signals triggers connotations of therapy?”

After reading the blog, a friend of mine – a clinical psychologist himself – offered something along the lines of, “Maybe the reason your work is effective is because you include some psychology.” No, I bristled. Staying within my scope of practice is important to me, and certainly anything that qualifies as psychology is beyond what a dietitian can offer, I reasoned.

Given that, I have occasionally second-guessed myself when conversations with patients have strayed into more distant orbits around food. On one hand, I have tended to listen to my instinct to prioritize what my patients want to discuss and to follow the natural flow of conversation so long as what we are talking about ultimately relates to their eating. On the other hand, when conversations become less about nutrition and more about things like body image, weight stigma, or even happenings in someone’s life that are tangential to their eating, I have worried that perhaps I have inadvertently crossed the line from where a dietitian’s work ends and that of a therapist begins.

Then along came a session at the 2021 Multi-Service Eating Disorders Association (MEDA) conference that alleviated my worry and helped me to see the matter in a different light. In their talk, entitled “Staying in Your Lane – Until You Can’t: Balancing Scope of Practice and Competent Client Care,” Anna Lutz and Sandra Wartski, a dietitian and psychologist, respectively, delved into the issue of professional bounds.

One of the most validating concepts that I took away from their talk is that there is no crisp line separating the work of the two professions, but rather there is an overlap, a gradient that bleeds from one realm of expertise into the other. In other words, some topics, such as weight stigma, are appropriate for discussion with both a dietitian and therapist, and each practitioner can bring different perspectives that hopefully complement one another.

Furthermore, scope of practice is amorphous, fluid, and depends on context, such as an individual patient’s needs at a specific moment in time and the practitioner’s own comfort level. Sometimes a patient is unable to address the work at hand, and simply having a human connection is more constructive. Anna gave an example of a time when a patient was too preoccupied with other matters to discuss food, something I have experienced with patients of mine on occasion, so they spent the entirety of their appointment talking without ever discussing the patient’s eating.

Having said all that, scopes of practice can only stretch so far. If a patient raises an issue that is beyond my ability to expertly handle, such as a disclosure of trauma that they are hoping we can process together, I am responsible for making my limitations known. Similarly, a good therapist knows better than to delve into the specifics of nutrition. Part of the reason why collaboration between treatment team members is so important is because we can let each other know when something comes up that is better handled by the other practitioner.

For me, their talk validated my intuition and reassured me that the way I approach my work is well within my professional bounds. For our patients who are reading this, I hope hearing about their session resolves any lingering questions you may carry about possibly having overshared and similarly serves as encouragement to remain open going forward.

 

Reentry

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It’s hard to believe that we have been living in this pandemic for over a year. In some ways, it feels like the year flew by, but in other ways, it feels like 10 years have passed. Jonah and I have been lucky that we have been able to continue seeing patients remotely during this time. And we are fortunate that no one in our immediate family has gotten COVID. We’ve spent the past year plus ordering our groceries online to avoid going to the store, drastically cutting back on getting together with friends, and playing little to no tennis (only outdoors). Our daughter, who is nearly three years old, has not had that much disruption in her life, unlike school-age kiddos. While we had planned to put her into a nursery school in March of last year, we decided to hold off until we felt it was safe. Our tentative plans are to send her to preschool in the fall. Aside from having to wear masks outside, she has been blissfully ignorant of the pandemic.

Jonah and I were also lucky in the fact that we were able to get our COVID vaccinations back in February because we are healthcare providers. This has been a huge relief, although it hasn’t changed our behavior that much. We still get most of our groceries delivered, aren’t eating indoors at any restaurants, and are limiting our socializing to outdoors. But we know that as the summer approaches, things will likely start to loosen up. More and more people will become vaccinated, outdoor activities will be more prevalent, and we will have more opportunities to socialize with friends and family.

While part of me is excited to start getting back to “normal,” I also have some anxiety about it. Like many people, I know that my body has changed over the past year. My pants are fitting a bit snugger, and my body just feels different. I’ve had to buy some new clothes to accommodate the changes, which has felt hard. And sometimes I feel my internalized fatphobia bubble to the surface. I worry what people will think of me when they see my larger body. I worry that others will judge me for weight gain over the past year. I worry that I won’t be good at playing tennis anymore. I worry that this body won’t be able to do the things it was able to do previously. I worry that I won’t be able to fit into different spaces.

I know that I am not alone in this anxiety around resurfacing post pandemic. Many of my patients have experienced changes in their bodies over the past year. We have all gotten used to seeing our friends, family, and co-workers via computer, with our views limited to the shoulders and up. It’s been a while since we have been fully visible to people other than family. In some ways, it has been nice not to worry about how our body might look to others. I know that I have seriously gotten used to wearing leggings and sweatpants to work every day, and it will be difficult to go back to office attire once we start seeing patients in person again! Telehealth has also made it easier for me to really focus on my patients, rather than being distracted by my own body.

One thing that I also have had to remind myself about is stress and its effects on weight. Our bodies are unbelievably smart, and when they are under stress (whether being chased by a sabretooth tiger or, you know, dealing with the uncertainty and fear of a pandemic), certain chemical processes are put in motion. One of these chemical processes is an increase in the stress hormone cortisol. When we are stressed, our adrenal glands release adrenaline and cortisol. Cortisol kicks off a release of glucose (our bodies’ primary source of energy) into the bloodstream in order to provide us more energy as part of the “fight or flight” response to dangerous situations. Increased levels of cortisol also cause an uptick in insulin levels, which results in our blood sugar dropping. As a result of this drop, we tend to find ourselves gravitating towards more energy-dense foods (i.e., foods high in carbohydrates and fat). This process also slows down our metabolism and increases our propensity to store fat in preparation for the next threat. All of these mechanisms have been in place in the human body since the beginning of time as a way of helping us survive. So it should be no surprise that many people have experienced weight gain over the past year as a result of living through an unprecedented pandemic. It’s our bodies’ way of trying to survive.

When I find myself perseverating on my body changing, I try to remind myself to breathe. Bodies change. That is what they do. Our bodies will change throughout our lifespan. It doesn’t need to signify something negative. My body has gotten me through this past year – it has survived a freakin’ pandemic! That, in and of itself, is an amazing feat. My body changed for myriad reasons, many of which I don’t know. Maybe it was ordering more takeout, playing less tennis, not leaving the house as much, feeling more stressed and anxious, or maybe it is just plain old middle age. In the end, it doesn’t matter. There doesn’t need to be a reason for my body changing, and there really isn’t anything I can (or should) do about it. I will continue to take care of myself and my body the best ways I know how, to give myself some compassion around reentering the world and remember that this amazing body has gotten me this far. I hope that your reentries go well too.

Exercise Checklist

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Exercise. The word alone carries a lot of meaning for many of my patients. For some of them, exercise is something that feels compulsive, that if they did not do it every day, they would feel panic. For other patients, exercise brings up old memories from childhood, such as when their parents forced them to exercise. One patient told me that when she was just eight years old, her father made her go for a run every weekday for 30 minutes to “help” her lose weight and be “healthy.” Not surprisingly, this patient has an utter hatred for running now. The word “exercise” itself can be triggering for some people as it feels intrinsically linked to diet culture. As we all know (insert sarcasm), exercise is “good for you” and therefore the more the better. “No pain, no gain” is another message that diet culture tells us about exercise. In other words, if it doesn’t hurt, you aren’t doing it right.

In my work with patients who struggle with compulsive dieting, disordered eating, and eating disorders, the question of exercise often will come up after much progress has been made with eating. A great number of my patients feel afraid to start exercising again for fear that they will get sucked back into diet culture. These patients worry that they will not be able to view exercise as something enjoyable and not required. They have concerns that their old thoughts about weight loss will start popping up again as they have associated exercise with changing their body. Some feel just completely overwhelmed at the idea of moving their body in a way that feels good because they had been so used to suffering through boring, pain-inducing workouts. And still other patients are at a loss as to what physical activity they actually enjoy.

One tool that many of my patients have found helpful is a “checklist.” It is a list of questions to consider before engaging in physical activity. The goal of this list is to help the patient check in with their body and decide whether or not they want to be physically active, and if so, what kind of activity would they like to engage in. Here is a basic checklist:

  • Am I injured or sick? If the answer is yes, then it is likely that you should be resting and not pushing yourself to be active.
  • Have I eaten enough in order to do this physical activity? Am I hungry right now? If you have not been consistently feeding yourself, exercising would be contraindicated as doing so could put a lot of stress on the body. If you are hungry, then you should eat.
  • Am I well-rested? If not, you might be too tired to be physically active right now. Perhaps your body needs a nap.
  • What am I looking to get out of this physical activity? Different forms of exercise can help our body improve endurance, strength, or flexibility. And sometimes physical activity can boost one’s mood via stress relief.
  • Do I feel like I have to do this physical activity in order to deserve food today? If you feel the answer is yes, try to reframe this thought. You deserve to eat no matter how much or how little you exercise. You do not have to “burn it to earn it.”
  • Am I using this activity as a way to try to lose weight or change how my body looks? Again, if the answer is yes, then some body image work could be indicated. Instead of asking yourself “how will this activity change my body?” try asking yourself “how will this activity make my body feel?”
  • What kind of activity would I like to engage in right now? Do I want something high intensity like spinning, something low impact like walking, or something very relaxing like yoga nidra?
  • If I don’t feel like moving my body right now, what else can I do? Maybe taking a nap or talking to a friend would feel best right now.

The checklist looks different for each patient, but at its core, it is about checking in with your body and trying to listen to what it is telling you. The more that we can practice checking in with our body around its needs – including but not limited to food, physical activity, sleep, and stress relief – we will be able to develop and foster body trust.

Here Comes Mr. Greedy

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When I ask my patients to look into their pasts and tell me about the origins of their weight stigma, they can sometimes trace back and point to influential entities, such as a parent, teacher, doctor, or coach. In relatively rare cases, they can recall specific interactions, such as Joanne’s doctor telling her to “get skinny,” or my neurologist cautioning me that if I ever thought about “slacking off” in my exercise routine, I should remember the conversation we were having right then.

Most typically though, patients cannot point to anything. They look at me befuddled, as if I asked a Red Sox fan how they came to know that the Yankees suck. Like, aren’t Bostonians just born knowing that? No, they are not; nor are we born prejudiced against fat people. Both mindsets are learned.

Just as dislike of the Red Sox’s longtime rival is ubiquitous throughout the metropolitan area, so is weight stigma in our culture at large. We develop sports team allegiances from a young age via various sources – jerseys in elementary school, endorsements, televised games, familial preferences passed down – and the biases that we hold against people of higher weights were shaped from so many sources that no singular one tends to stand out in our memories.

And these sources get to us when we are young. Our daughter loves books and has an extensive library of reading material geared towards toddlers her age. In a boxed set of children’s books from the late Roger Hargreaves, Joanne intercepted one entitled Here Comes Mr. Greedy, which shows a cartoon of a fat man on the cover. Subsequent pages describe this rotund individual as “the greediest person I’ve ever met,” that he constantly thinks about food, and he is so “greedy” that he throws a birthday party for himself every week so he can regularly have his favorite food: birthday cake.

This is just one book that Mr. Hargreaves wrote that features his Mr. Greedy character. Another one reads in part, “In fact, Mr. Greedy loved to eat, and the more he ate, the fatter he became. And the trouble was, the fatter he became the more hungry he became. And the more hungry he became the more he ate. And the more he ate the fatter he became. And so it went on.”

Nothing against Mr. Hargreaves, who seemingly dedicated his professional life to creating content for children. Like most of us, he was an apparent victim of a fatphobic culture. Mr. Hargreaves presumably absorbed erroneous stereotypes about eating behavior and body size and repackaged them for preschoolers, thereby perpetuating the generational cycle of fat hate.

Sparing our offspring from weight stigma is certainly an uphill battle, but parents have the ability to take mitigating actions.

For starters, parents can minimize exposure. Just as Joanne spotted Mr. Greedy in our daughter’s new book collection and removed it, we can be vigilant in other ways. Change the channel when ads for weight loss programs and products come on, set appropriate boundaries with those who talk about their diets on family Zoom calls, and find a pediatrician who provides weight-neutral healthcare.

When children inevitably encounter weight stigma, address it head-on and help them process it. Teach them that bias against body size is as erroneous and problematic as any of the other stereotypes and prejudices that infect our world.

Most importantly, even though what happens out of the house is largely out of our control, make sure to keep a body positive environment at home. Avoid leaving problematic magazines on the coffee table (or better yet, do not keep them in the house at all), get rid of the scale, do not go on diets (or embark on “lifestyle changes” that are diets in disguise), and refrain from offering disparaging comments regarding anyone’s bodies, including our own.

The “T” Word

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

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

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

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

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

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

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

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

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

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

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

“Food Addiction”

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

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

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

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

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

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

Questionable Measures

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

 

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

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

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

Coming Out

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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