No Nutritional Value?

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People sometimes use the phrase “no nutritional value” to demean certain foods or to flagellate themselves or someone else for having consumed one of them. Whenever someone speaks these words, I curiously wonder: Do they mean the phrase literally or figuratively? Either way is problematic, unfortunately, and is indicative of room for growth in their relationship with food.

If someone perceives that a food literally has no nutritional value, chances are high that they are factually incorrect. Anything we eat that contains at least one macronutrient (carbohydrate, fat, protein, water, or alcohol) or micronutrient (vitamin or mineral) has – by definition – nutritional value. Check out a food’s nutrition label, and if you see any numbers other than zeros, you know it has nutritional value. Even if you see zeros across the board, unlisted nutrients are still likely present, or perhaps the quantities are low enough that labeling laws allow for rounding down to zero. Sitting here now, I am hard-pressed to think of even a single example of an edible entity that has literally no nutritional value.

Besides, criticizing a food for having little or none of a particular nutrient implies that other foods with higher concentrations of it are somehow superior, but this is not necessarily true. Some nutrients have a tolerable upper limit, which is the “maximum daily intake unlikely to cause adverse health effects.” For example, consuming too much zinc can cause a copper deficiency, as the two minerals compete for absorption. People have died from drinking so much water that their blood’s sodium concentration became perilously low. Vitamin A toxicity, which can also be fatal, can arise from eating just a single serving of polar bear liver.

Even if we consider smaller quantities, ones not large enough to seriously risk our health, consuming too much can prove useless. Purchase a supplement with a high concentration of B vitamins and note how your urine turns neon yellow, which results from our bodies expelling the excess vitamins it cannot use. (Insert here your own joke about flushing your money down the toilet.) Taking in a large amount of calcium at once does little good for our bones, as our bodies are limited in how much they can absorb at a time. The bottom line is that more does not always imply better or healthier.

Having said that, I know that most people who say “no nutritional value” do not mean it literally, but rather as an expression of how they deduce foods, ingredients, and nutrients into moral hierarchies. For example, someone may tell me pasta has no nutritional value because they see carbohydrates as inferior to protein. Another person may claim that butter has no nutritional value because they look down upon its high fat concentration. Yet another patient may say that juice has no nutritional value because their demonization of sugar blinds them from appreciating the vitamins, minerals, phytochemicals, and other nutrients swimming around in the beverage.

People are often hard on themselves or feel anxious for eating foods that they perceive as having no nutritional value, which hinders their ability to eat intuitively. Recognizing our body’s signals can sometimes be challenging enough even without guilt and stress complicating matters and clouding the picture. One of my patients described the situation to me with a simile, saying it is like playing a sport and straining to focus on what the coach is saying while other people on the sidelines loudly yell conflicting advice. Similarly, if we feel virtuous for eating a food that we perceive to have nutritional value, we might be at risk for blocking out signals from our body that the food is not actually hitting the spot.

See if this common scenario feels familiar. You are in the midst of eating a food that you perceive to have “no nutritional value.” Even though you can tell you are getting full, you decide to keep eating it because you figure today is ruined anyway, so you might as well finish it all so it is no longer in the house, and you can start fresh tomorrow. Here is another situation that might ring true. You are craving a specific food, but since you feel it has “no nutritional value,” you try to satisfy the craving with an alternative version that you believe has a better nutrition profile. Since the latter does not quite hit the spot though, you consume more of it in an attempt to make up for lack of pleasure with quantity. Still not satisfied, you try other foods. Your grazing may eventually encompass eating the food that you craved in the first place. Now you feel stuffed and maybe guilty, whereas if you had allowed yourself to consume the object of your desire in the first place, you could have had a more enjoyable and peaceful eating experience and then gotten on with your day.

When I was in nutrition school, I used to modify my cookie recipes in an attempt to make them “healthier.” It took me a long time to understand why I tended to eat so many of these modified creations in one sitting, but eventually I realized it was because these cookies – which were more akin to high-fiber pancakes than actual cookies – were not hitting the spot. That is not a knock against pancakes, which are of course fine, but they do not fill a cookie-shaped hole as well as the real thing. Once I came to understand what was happening, I abandoned those modified recipes and returned to the original. Instead of having a whole pile of the “healthier” but less satisfying versions, I would have a couple of real cookies, feel satisfied, and be done.

If any of what you have read here resonates with your own thought patterns or experiences, ask yourself this: How might my own eating change if I abandon the flawed notion that some foods have “no nutritional value”?

Credibility

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The Academy of Nutrition and Dietetics (AND) recently issued a draft of their updated clinical practice guidelines regarding medical nutrition therapy interventions for what they term “adult overweight and obesity treatment.” The very last point in their draft recommendations reads, “For adults with overweight or obesity, it is suggested that RDNs [registered dietitian nutritionists] or international equivalents not use a Health at Every Size® or Non-Diet approach to improve BMI [body mass index] and other cardiometabolic outcomes or quality of life.”

As you can imagine, the Health at Every Size (HAES) community is pushing back against the AND’s draft recommendations. The Association for Size Diversity and Health (ASDAH) published an open letter to the AND as well as one to the HAES community outlining the ways in which the AND’s position is problematic.

(Before continuing, I want to highlight that the latter publication makes reference to white supremacy and how it factors into the picture, which I can imagine might trigger some head-scratching from those unfamiliar with the history of diet culture. If you want to learn more about this topic, consider checking out Fearing the Black Body – which, to be candid, I have not yet read myself, so I am calling attention to it based solely on its excellent reputation – or the first chapter of Anti-Diet.)

While I do not always agree with ASDAH and we do not speak for each other, I completely support the sentiments conveyed in their response letters. Similarly, I agree with Ragen Chastain’s response, which goes into more detail than ASDAH’s letters. Rather than reiterate their same points, I want to take a step back and look at one of the dynamics at play in this situation and in healthcare in general: credibility.

Back when I was in school for nutrition and looking ahead to my career, I wanted to become a universally respected expert, which is one of the reasons why I worked so hard in school. Then I began my dietetic internship and quickly began to sense that my expectations might be unrealistic. While all of my clinical preceptors placed a great deal of emphasis on note writing, or charting, each of them differed in how they wrote them, yet each felt strongly that their way was best and the others were wrong. One preceptor would praise me for utilizing a writing style for which another preceptor would chastise me. With my superiors giving me contradictory guidance, I felt confused and a bit paralyzed. There was no winning, no way in which I could make everybody happy, for what they each wanted from me was mutually exclusive.

Once I began practicing, the theme continued. Each time I changed how I practiced, some patients and colleagues applauded my shift while others thought I was making a mistake. Forget striving for universal respect, as there is no such thing. Credibility is subjective, and the truth is that every practitioner, no matter their approach, level of success, or reverence, is still seen by many as a quack.

This dynamic is not unique to dietetics; it shows up in other branches of healthcare as well. Reflecting upon issues I was having with my back in late 2013 and early 2014, I remember meeting with six surgeons – all of whom were highly regarded – and receiving five different opinions regarding what type of surgery I should have. One of them went so far as to say that if one of his interns had recommended the procedure that his colleague had suggested for me, he would have given the intern a failing mark.

Just as I had to weigh the pros and cons of the surgical options and choose the one I felt was the best for me, practitioners and patients also must decide which approach to healthcare is the one for them while understanding that large groups of people will always think their decision is wrong no matter what they choose.

When I first discovered HAES, I was skeptical since it contradicted much of what I had learned up to that point. Additionally, I did not want to believe it because it posed a threat to the weight-focused care I was providing at the time. On a deeper level, admitting HAES had validity also meant having to face the harm I had inadvertently done to my patients. Nobody who chooses a career in a helping profession wants to admit that they instead brought about hurt. Perhaps the folks at the AND – an organization that reinforces diet culture and weight stigma – are feeling similar resistance now, hence their criticism of HAES, or perhaps they are critical of HAES simply because it is not the approach that they choose to practice themselves.

Matching

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Figuring out what to eat can sometimes be a challenge. We stare at the contents of our open refrigerator, knowing we are hungry but unsure of what to choose, before we close the door only to immediately open it again and resume the search. We ask the waiter to come back in a few minutes and then return our attention to the menu. Our uncertainty can lead to frustration, confusion, and wasted time, but we have a remedy: matching.

Matching is an intuitive eating tool that can help us to make food selection decisions based upon our body’s internal cues. Diet culture tells us not to listen to our bodies, that its cues are untrustworthy and therefore to be ignored in favor of external systems, such as points systems or lists of foods to eat and those to avoid, in order to make choices.

However, our bodies are actually quite good at letting us know which food is going to hit the spot at any given time. As examples, consider how much better water tastes when we are thirsty compared to when we are already well hydrated, or how some people with anemia feel naturally attracted to high-iron foods. The latter might not know that beef has a high concentration of heme iron, but they do know that right about now, they could really go for a burger. Our bodies give us signals; we just have to be tuned in enough to notice what they are saying and trust them.

Following is an outline for how to put the matching process into practice.

  1. Before opening the refrigerator, pantry, or restaurant menu, ask yourself these questions to help guide your decision based upon your body’s intuitive eating cues.
    1. “What temperature food do I feel like having?” Example answers include hot, lukewarm, room temperature, cool, or frozen.
    2. “What texture food do I feel like having?” Example answers include crunchy, smooth, liquid, or a combination.
    3. “What color food do I feel like having?” Example answers include multicolored or monotone in a specific color.
    4. “What flavor food do I feel like having?” Example answers include sweet, salty, spicy, or bitter.
  2. With your answers in mind, survey your available food options to see which ones match – hence the term “matching” – your criteria.
  3. Imagine yourself eating each of the options you identified and choose the one you feel is most likely to hit the spot.
  4. Eat the food you selected, then ask yourself how the eating experience compared to your expectations. If your choice hit the spot as you anticipated, great! If not, no worries, just consider it data for the future.

You probably will not be able to answer all of the questions regarding temperature, color, texture, and flavor, but being able to answer even one can be enough to point you in a direction. Also, these are not leading questions, and you are not trying to talk yourself into wanting – or not wanting – a particular food.

Lastly, keep in mind that the matching process is a tool, not a rule that can be violated. For example, if you go through the process and determine that you want crackers and cheese, but then you remember that you have yogurt that is about to expire and you opt to use it up instead, you are not doing anything wrong, nor are you bad at intuitive eating. We all live in the real world where a multitude of factors influence our eating, and it would be unrealistic to expect someone to always base their eating decisions solely on matching. Use this tool to the extent that you want to and find it helpful.

“You have permission to not eat.”

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Some of my patients who are relearning how to eat intuitively find it helpful to utilize a mantra, a phrase they can say to themselves to help them through a challenging situation. Because we often discuss the concept of unconditional permission, “You have permission to eat” is a refrain that my patients commonly use. One of my patients though flipped it on its head and began to use “You have permission to not eat.” At first, I was a bit perplexed, but the more I listened to her and reflected on these words, the more I realized their power.

Having the freedom to allow ourselves to eat whatever we want, whenever we want, and however much we want – otherwise known as unconditional permission – is central to intuitive eating. Without this foundation, everything else we study can easily warp into dieting tools. Given that, I initially bristled at “You have permission to not eat” because I thought it might be a veiled attempt at restriction, but that is not the case at all. Rather, the power in these words comes from acknowledging the times when we feel obligated to eat even when our bodies are saying no and freeing ourselves from the burden of feeling powerless.

As a first example, consider the scenario that my patient told me about when she was explaining the power of her mantra. She was at dinner with her extended family, and all of the latter were leaning towards ordering dessert. While my patient did not feel like having dessert, she also felt a social obligation to order it since others were. Then she reminded herself, “You have permission to not eat,” which reaffirmed that whether or not to order dessert was her prerogative, and she could act in her own best interests regardless of how the rest of her family went about their eating.

Thinking about other possible applications, I realized how helpful this mantra can be for people who feel pressure to not “waste” food. We are familiar with guilt-inducing refrains to clean our plate, such as “There are starving children in the world,” as if whether or not we finish the food in front of us has any impact whatsoever on the global politics of food insecurity. In these moments, “You have permission to not eat” reminds us that we do not have to be human garbage disposals for the sake of some theoretical benefit to others.

My thoughts then went to how this phrase could be useful for people working through compulsive overeating. Recovery is, of course, more complex than simply reciting a mantra, but just as the concept of unconditional permission is essential for diet survivors who are building healthy relationships with food, “You have permission to not eat” reminds compulsive overeaters that they have the freedom to move away from the urges to overconsume that have felt so irresistible.

Lastly, I considered how “You have permission to not eat” can aid those who overconsume due to habit or tradition. Maybe we eat to the point of physical discomfort every Thanksgiving because we have come to accept that this is the norm on the holiday, or maybe we buy popcorn every time we go to the theater regardless of whether or not we are hungry or feel like popcorn just because eating the snack feels like an intertwined and essential component of movie watching. “You have permission to not eat” reminds us that even if we have long engaged in certain eating behaviors, we have the freedom to move away from them if we feel that they no longer serve us.

You may discover other applications in which “You have permission to not eat” is a helpful mantra, but guard against the temptation to use it as a tool to restrict because that would likely backfire and be counterproductive. If you feel yourself tempted to go down that road, remind yourself of the phrase from which this mantra came: “You have permission to eat.”

“What should I do for exercise?”

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When the topic of physical activity arises, a common question I get – especially if the patient knows I used to work as a personal trainer – is some version of, “What should I do for exercise?”

Before I get to my answer, a little history: Back when I was in nutrition school and working on the side as a trainer, I began my relationship with a new client by asking about their exercise-related goals. With their answer in hand, I researched the best (in theory, anyway) physical activity approach towards achieving said goals. Whether or not the client enjoyed my exercise prescription was largely immaterial. I offered a means to an end, and they were going to do what I suggested whether they liked it or not.

Furthermore, my clients hardly seemed to mind my approach. They expected trainers to have a no-pain-no-gain mentality, an element of an exercise-as-punishment culture that is so harmful yet prevalent, and I was giving them what they thought they deserved. Clients wanted clear and crisp answers, and I was providing them. Whether I was right, wrong, or somewhere in between seemed a distant consideration to the reassuring comfort that came with being told what to do.

At this point, I should add that I was a fairly horrible personal trainer. With hardly any experience, little oversight, and no mentors, I was on my own to take what I had learned in academia and apply it to the real world. Humans, it turns out, are way more complicated than straightforward case studies in a textbook. Clients became burnt out, got hurt, lost interest, or dropped off for other reasons, and they almost always blamed themselves instead of my flawed approach.

If that sounds similar to how dieters tend to place the blame for weight regain on themselves rather than on the diet, know that the parallel stands out to me too. Just as I cringe at the way I used to train clients, I am embarrassed and ashamed of how I practiced dietetics at the beginning of my career. The difference is that I have been a dietitian long enough to have outgrown those painful beginnings, whereas I worked as a trainer for such a short time that just when I was beginning to recognize my mistakes, it was time to move forward in my career.

When patients ask me about exercise, I now know that the straightforward answers they want and expect – the very kind of answers that I used to provide as a trainer – are not all that helpful even if they would be welcome. Just as is the case when it comes to our relationships with food, our relationships with physical activity are nuanced and unique. The answers come about through discussion and collaboration. Here are five factors that I encourage my patients to consider:

  1. Enjoyment: My decision to lead with a factor that is often shoved towards the end of the priority list or set aside entirely – yet in my eyes is so essential to consider – is a conscious one. If you do not like doing an activity, how likely are you to sustain it? If you repeatedly put yourself through an unpleasant experience, what kind of ripple effects will that have in the rest of your life, whether it be seeking out rewards, being in a bad mood, etc.?
  2. Risk: We can get hurt doing literally anything, but some activities are riskier than others. Injury risk also depends on the person in question. For example, some people can run their entire lives, whereas a friend of mine had to give it up due to a recurring injury that arose whenever he attempted to resume jogging. Risk extends beyond musculoskeletal concerns and includes other factors, such as a maximum heart rate that a cardiologist may suggest their patient not exceed.
  3. Access: If you enjoy swimming but cannot afford a pool membership, or you like walking but live in a mosquito-infested area without sidewalks, or you are into a team sport without a league in your area, you will face more challenges than someone with ready access to the facilities and opportunities they need.
  4. Goals: Choosing activities that advance us towards our goals increase our chances of achieving them. An aspiring strongman will get little benefit from participating in cycling brevets, whereas someone with osteopenia in their hips may be better off skipping both of those pursuits entirely and instead going for a walk.
  5. Options: Remember that physical activity is comprised of more than just “exercise” in that the latter typically conjures images of things like elliptical machines and dumbbells, whereas the former is broader and can include gardening, cleaning, shopping, dancing, hiking, chair yoga, isometric contractions, and anything else that engages the body.

So, what should you do for exercise? Look for a mode that you enjoy, have ready access to, makes you physically feel good, and helps you towards your goals. Whatever your answer is, that is what you should do for exercise.

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.

 

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.