Author Archives: Jonah Soolman

Misguided and Deplorable

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You already know that last fall in New York City, a gunman murdered Brian Thompson, CEO of UnitedHealthcare. Yet, as I sit here watching the executive branch of our federal government simplistically blaming scapegoats for complex issues, this piece of old news feels relevant.

What a misguided and deplorable act, but we can understand the gunman’s anger, right? It is hard to be worse than Medicare – which once rejected an 18-page application that I filed without telling me why, and it turned out it was because I listed my five-digit zip code instead of also including the four-digit extension – and yet United found a way. In fact, I would estimate that we have had more issues with United than with all of the other insurance companies we deal with combined.

On the provider side, our problems with United began very soon after we applied to be credentialed as in-network providers. Based on the paperwork we received, our impression was that we became in-network providers in the spring of 2013, but United subsequently told our billing manager that we were not in network and never had been, so we reapplied in early 2014. They sent us letters notifying us of our acceptance, but the contracts we were supposed to sign never arrived. As the redacted fax that I sent them in August 2014 shows, United provided contradictory information and made getting a straight answer very difficult.

Contradictory information seems to be United’s trademark, as I have lost count of the number of times they told our patients that their appointments with us would be covered, only to later reverse course. It got to the point where I now candidly warn our new patients with United that there really is no way of knowing for sure ahead of time what their coverage will be, that we all just have to wait until the reimbursement statements arrive to find out.

The worst United story that I have heard came from a woman I know personally who was telling me about her sister. Before undergoing joint replacement surgery, her sister contacted United to make sure the operation would be covered. She shared all of the details, and United assured her that they would cover the procedure. Soon after the surgery, she received a six-figure bill from the hospital, as United had gone back on their word and declined to cover the operation. Their reason? Apparently, in addition to the surgeon, another doctor had been present in the operating room during the surgery, and this doctor was out of network with United. Based on the presence of the out-of-network doctor, United decided not to pay. The patient had made sure ahead of time that her surgeon was in network, she was literally unconscious during the procedure and had no control whatsoever over who else may have ended up in the room, yet United left her hanging with a bill on par with that of a mid-range Porsche.

Right around a decade ago, Joanne and I were talking with a colleague and bemoaning the difficulties of working with United and other insurance companies. She encouraged us to remember that the job of insurance companies is not to pay, that the challenges we were facing are by design. The more barriers that they put up during the reimbursement process, the more likely that the patient will ultimately get stuck with the bill, which just serves as a reminder that for-profit healthcare will never make any sense except in the minds of the depraved.

Then again, neither does committing murder as a form of protest. A man lost his life, the gunman effectively threw away the remainder of his own, and for what? Mr. Thompson was a high-ranking executive in a wicked and deeply flawed system, he has been readily replaced by another executive who will carry on the same mission, and nothing will change except the addition of a security detail.

Our healthcare system has serious problems, and we need thoughtful, intelligent, well-informed, and compassionate leaders to sort them out, not someone who resorts to scapegoating, hate, and violence. Same goes for our country.

The Potato Diet

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A couple of decades ago, a nutrition professor told me that one of the reasons she loves being a dietitian is because when people hear what she does for a living, they are interested and want to talk with her about the field. In contrast, most practicing dietitians I know dislike talking about their work, so much so that some of them purposely shade what they do, such as saying, “I work in healthcare,” or “I am a therapist,” in order to discourage follow-up questions. It’s not that these dietitians hate their jobs or anything; rather, they do not want to get sucked into irritating conversations during their free time.

Personally, I have found that quickly adding that I specialize in eating disorders tends to keep at bay the annoying questions and commentary that are more likely to arise when I simply say that I am a dietitian and leave it at that. My approach, while usually successful, still has its failures, as evidenced by an experience we had last month in a Puerto Rican swimming pool.

Joanne and I were on the island vacationing with our daughter, and we ended up in conversation with another couple who were also enjoying the hotel pool with their son. Upon hearing what we do for work, the father began talking about a favorite dietary approach of his: the potato diet.

Given that the potato diet is actually a real thing, let’s talk about this guy’s diet of choice. According to him, the potato diet consists of eating nothing but potatoes and supplementing with vitamin E because, according to him, potatoes – when eaten in abundance – contain sufficient amounts of all nutrients except for vitamin E. He also claimed that the diet “works” without ever defining what constitutes success in this context, although he did make mention of a celebrity who supposedly lost a significant amount of weight on the potato diet, thus suggesting that “works” means something along the lines of “will cause someone to lose weight.”

Okay. So, according the USDA’s nutrient database, a generic large russet potato, including its flesh and skin, is said to provide 292 calories. For a generic person who needs 2,000 calories per day (and many of us need more), that means eating nearly seven of these large potatoes a day. Putting aside the feasibility of that for the moment, would seven potatoes per day really contribute enough of each nutrient besides vitamin E? Let’s take a look.

The low end of the recommended carbohydrate range is 45% of total calories, so the person needing 2,000 calories per day would need at least 900 calories, or 225 grams, of carbohydrate from these seven potatoes. Because potatoes are densely packed with carbohydrates, they would easily exceed this minimum. Check mark.

What about protein? Estimated protein needs are based on body weight, activity level, and medical conditions, so let’s say that the person in question weighs 130 pounds, is generally sedentary, and has no medical conditions that would influence their protein needs. The low end of their protein range would be about 47 grams per day. Their seven potatoes would contribute 55 grams, so check mark again. If the person is heavier, more active, or has higher protein needs for any other reason, this check mark is probably replaced with a red X.

How about fat? The low end of the recommended fat range is 20% of total calories, so this person would need at least 400 calories from fat, or approximately 44 grams. Their seven potatoes only contribute a couple of grams total, so a huge red X here.

Unfortunately, the low fat content spells trouble for the fat-soluble vitamins. Russet potatoes do actually contain some vitamin A and K, but too bad the dieter’s body will be unable to absorb it due to the lack of dietary fat. The same would be true with vitamin D if the potatoes actually contained any, which they do not.

The seven potatoes do contain enough vitamin C to stave off scurvy, and the thiamin content is enough to prevent beriberi disease, but the lack of vitamin B12 would likely cause fatigue and, if sustained long enough, possibly anemia. We could go on, talking about other micronutrients, phytochemicals, and other nutrients, but you probably already realize that the potato diet is not a great idea if the goal is any semblance of health.

But what if the goal is not actually better health but rather, say, weight loss? (And remember, weight and health are not synonymous.) Personally, I imagine that the first couple of potatoes on day one would taste great, but by potatoes six and seven, I would already be sick of them. In subsequent days, I would probably be so tired of them that I am not sure I could continue to stomach all seven even if I was still hungry. Restricting variety to just one food carries the likely intended side effect of restricting one’s intake overall, and while restriction does not always lead to weight loss, sometimes it does, at least in the short term.

And isn’t that really what the potato diet is? Just another fad diet to bring about short-term weight loss that will likely be regained plus more? Instead of focusing on our daughter and having a good time, we had to spend a portion of our vacation talking with this guy about this nonsense. See, this is why so many dietitians hesitantly offer some version of, “Umm, I work in healthcare,” and then try to change the subject.

Nutrition Counseling in the Age of AI

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Listening to my niece and nephew talk about the role that artificial intelligence (AI) is playing in their college academic experiences, I started thinking about AI’s impact on my profession, including what possible future human counselors will have in an age of machine learning.

Long before AI became part of our vernacular, technology had already eaten into the role of registered dietitians. Why bother seeing a dietitian when we have search engines, some would argue, and to an extent, these folks have a point. Some patients are only interested in information that is readily available online. Sure, online information can be of questionable quality, but we dietitians are wrong sometimes too, so accuracy is not guaranteed either way.

One of the issues with relying on online health information is applicability. At some point, I read a study that looked at people who self-diagnosed using WebMD and then got a formal diagnosis from a doctor, and the discrepancy between the two was quite high. So, sure, we can hop onto the internet and readily find the medical nutrition therapy protocol for treating various conditions, but what if the condition we believe ourselves to have is more nuanced than we realize or just plain incorrect? AI, of course, is more advanced than a simple search engine, and from my layman’s perspective, it seems to be continuously improving at a rapid rate. The interactive nature of AI has the potential to reduce self-diagnosis errors.

If all patients wanted was information, the future of nutrition counseling would look quite grim, but many people are looking for more than just knowledge and data; they want a human connection. They want to talk with someone who can relate to their own challenges – not because that someone is a something that has absorbed enough data about said challenges to have assembled appropriate responses and follow-up questions – but because that someone has lived experience and has felt scared, nervous, sad, excited, or however they are feeling in the midst of whatever situation has inspired them to find a dietitian. That human dietitian has genuine empathy.

An AI entity can spit out the right words and tone, can mimic empathy, but it remains – as the name suggests – artificial, and no matter how the technology evolves, this basic fact will never change.

Weight Loss Wagering

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When I began working on this piece, I was trying to remember when I first learned about the idea of betting on weight loss and what my reactions to the concept were back then. As far as I can recall, I think it was around 2009 or 2010, and I believe I was intrigued, as this was at a point in my career when my work was centered around instigating weight loss (or its close cousin, improved body composition) and the assumption that of course such pursuits lead to better health. So, if wagers could be a useful tool in my proverbial toolbox, I wanted to know about it.

While the idea of wagering on weight loss continued to exist, it never really took off or hit the mainstream either, at least as far as I could tell, but it caught my attention again early last month when I noticed that HealthyWage [Note: They seem to use HealthyWage and HealthyWager interchangeably on their website.] was running ads during the US Open tennis tournament. My reaction now, 14 or 15 years later, was quite different than when I first heard about betting on weight loss.

Using weight as a proxy for health – which a younger me left unquestioned and unchallenged for way too long – is problematic in itself, but we have already covered that elsewhere, so I am going to put that aside, as many other topics are going through my mind: Does the prospect of winning or losing money in the short term actually induce long-term behavior change? How do outcomes differ when someone wagers against themselves as opposed to engaging in a weight loss competition against a friend or others?  Addressing these and other questions that I have in mind would be too lengthy for a single blog, but perhaps I will circle back to them one day.

Meanwhile, I want to take a narrower focus and examine a few of the company’s claims and pieces of information that most stood out to me when I spent some time exploring HealthyWage’s website.

Clicking the “Get Started” button on the homepage brought me to a calculator where I could change my prize range by manipulating how many pounds I want to lose, how much money I want to bet each month, and how long I need to reach my weight loss goal. Regarding length, I noticed that the more time I asked for, the higher my prize range, which runs counter to the old adage that trying to lose weight slowly and steadily is more likely to be successful than rapid weight loss, advice that I used to echo early in my career and that some doctors still repeat to their patients. In reality though, this advice is nonsense, as weight loss endeavors will likely fail in the long run no matter how they are pursued. While we can be relatively successful inducing short-term weight loss, the weight almost always comes back in the end. HealthyWage’s algorithm suggests that they understand that long-term weight loss is less likely, as evidenced by their willingness to fork over more money to the people who achieve it and less money to those who quickly lose the same number of pounds.

Going back to the homepage and scrolling just below the “Get Started” button yielded testimonials from three “Success Stories,” including names and locations of three individuals who won between $1,463 and $3,007 via losing 101 to 160 pounds in contests that ranged from nine to 18 months. In addition to their statistics, these profiles also feature before and after photos as well as quotes from the individuals. You know who else posts success stories? The Massachusetts State Lottery Commission, for one, whose website lists hundreds of winners per day across the state. According to a study by Bloomberg, state lotteries “have the worst odds of any form of legal gambling” in the country. To put things in perspective, one is reportedly four times more likely to get hit by an asteroid than they are to win Powerball. Testimonials – whether they are lottery winners posing with oversized checks, Weight Watchers leaders touting their own journeys in front of their groups, or HealthyWage winners – sure are enticing by inducing fantasies of what is possible, but possible and likely are vastly different adjectives.

One question on the HealthyWage FAQ page asks, “Is HealthyWage legal?” to which the company responds, “Yes. Although we use the word ‘bet’ to explain the concept, HealthyWager isn’t gambling in the legal sense because you are in control of the outcome at all times. It’s up to you to lose the weight.” Okay, first of all, suggesting that weight loss is entirely in one’s control is incorrect, reckless, and contributes to stigma. Joanne and I have both had patients who were still fat despite struggling with very restrictive and dangerous eating disorders, and I take issue with the false narrative that someone is whatever size they are solely because of their behaviors. Furthermore, the “at all times” phrase flies in the face of solid evidence showing that weight regain is the norm, not the exception.

HealthyWage can call their service whatever they want, but the fact remains that it is a gambling operation similar to state lotteries, casinos, or any other for-profit entity that invites customers in with splashy hooks and enticing testimonials. When we put our fantasies of victory aside and get back to reality, we remember the basic truth of this industry: The house always wins.

Biting Lollipops

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Don’t bite your lollipops, I always warn our daughter. Well, I failed to follow my own advice, broke a tooth, and ended up with my first crown.

Sometimes we have to learn our lessons the hard way, a theme that I often think about when I am working with my patients. In motivational interviewing, the urge a practitioner may feel to tell their patient what to do is called the “righting reflex,” which is generally an unhelpful tactic that I do my best to avoid.

Sometimes I worry when my patients make choices that seem unlikely to work out in their favor (setting out to lose weight, spacing out appointments differently than I feel they should, declining to read a book that I think would be helpful for them, choosing to work with a therapist or doctor whose area of expertise is a mismatch for their conditions, keeping a scale in their home, just to give a few examples), but such concerns are my problem, not theirs.

After all, my patients are the stars in their own lives while I am part of their supporting cast, and they have the autonomy to consider all aspects of a decision before making the choice that feels best to them. The choice that I think I would make in their shoes or what I believe they should do are irrelevant, unless the patient asks for my opinion and wishes to consider it along with all of the other factors at play.

Although I am open to offering my opinions upon request, my job is much less about telling someone what to do and much more about helping them to understand and consider the pros and cons of their options. For example, over the summer, one of my patients received weight loss advice from their doctor, guidance that is outdated and highly unlikely to achieve the doctor’s expected results. Being caught in the middle between treatment team members with differences of opinion is confusing, frustrating, and just no fun. The appointment that we had in which I warned them of the dangers inherent with the doctor’s advice was a tough one. Ultimately, I hope they understood that my dissent was not really about trying to sway them, but rather about helping them to see the whole picture, thereby enabling them to make an informed decision regardless of whatever that decision might be.

Someone might understand that biting lollipops is a dangerous idea, but they love biting them so much that the risk feels worth taking. Fine. On the other hand, to break a tooth on a lollipop without knowing that biting them is risky, that would be a tragedy. Sometimes, intellectually understanding that something is a bad idea is insufficient; we have to make our own mistakes in order to learn. Sometimes we need to break a tooth of our own to truly understand that biting lollipops is perhaps a roll of the dice best not taken.

We are all going to die!

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One of my patients, who has been working hard to refine their intuitive eating skills, recently asked me to explain the concept of gentle nutrition in general terms. Although I already wrote a piece about this topic just last year, I want to revisit it because I realize in hindsight that I failed to adequately emphasize a basic truth that is of upmost importance to remember: We are all going to die!

Yes, yes, eye roll, we are already aware of our mortality, but thinking about our demise can be so unpleasant that it can be easy to put to the side and ignore. As scary and sad as it can be to think about, sometimes we need to remind ourselves that no matter how fast and how far we run, death will always chase us down. Always. Unless we get hit by that proverbial bus or suffer some sort of other physical trauma, a health condition of some form will do us in. That’s just how it is.

While death is a certainty, how exactly it will happen will remain a mystery until it actually unfolds. Some smokers never develop lung cancer while some non-smokers do. Predictions, like weather forecasts, are still just guesses. Sometimes the weatherman calls for a 5% chance of precipitation and we get a downpour.

Of course our overall dietary pattern has some influence, albeit limited influence, over our health, but the impact of any single eating occasion is likely negligible. Unless the food blocks or closes our airway or somehow inflicts catastrophic injury to our gastrointestinal system, tonight’s dinner is not going to kill us, nor will it save us from our ultimate fate. Given that an elementary eat-this-not-that approach fails to account for our nuanced reality, how, then, are we supposed to make decisions about what, when, and how much to eat? This is where intuitive eating and gentle nutrition can help.

My patient gave me an example of a situation they found themselves in, and we talked through how one might approach it using intuitive eating and gentle nutrition, but I am going to tweak the specifics a bit for the sake of their privacy. My patient is reassessing their intake of red meat after reading an article linking such meat with colon cancer, which runs in their family. Furthermore, their go-to order at the local pizzeria is a steak and cheese sub. Should they be reducing their intake of red meat and perhaps be ordering something else, they questioned, or would that be running counter to intuitive eating?

My response began by reminding them that having a steak and cheese tonight will not kill them, nor will opting for a salad save them. We talked about using matching questions to help guide their food choice. If the matching process squarely lands on the steak and cheese, then yes, of course, go ahead and order it. On the other hand, if the criteria they identify are broader, they anticipate that they could take or leave the steak and cheese and be equally happy, and since reducing their intake of red meat is a goal they are trying to achieve, then opting for a different menu item probably makes the most sense. In essence, gentle nutrition utilizes medical nutrition therapy as a tiebreaker of sorts, not a driving factor.

Furthermore, we talked about increasing their options by considering items on the pizzeria’s menu that perhaps they had overlooked. In other words, the choice need not be binary between a steak and cheese sub or a garden salad, but also include a pizza with chicken and broccoli, a Greek salad with shrimp, or any of the other menu items that omit red meat.

During the course of our conversation, my patient realized that sometimes they order the steak and cheese by default, not because they necessarily have a craving for it, and that sometimes it leaves them with a stomach ache. This information is important to consider too. Sometimes their desire for the steak and cheese is so strong that it will feel worth risking a stomach ache, but other times the craving will be low enough that it will be overshadowed by wanting to feel good the rest of the night. Even more importantly, realizing and acknowledging that they sometimes make their ordering choice on autopilot offers an opportunity to make more conscious decisions going forward.

Hopefully, this addendum to the piece I wrote last year helps to clarify the concept of gentle nutrition. Perhaps, as I continue to think of better ways of explaining, you will see me release a third installment at some point. That is, if I live long enough to write it, and if you are still around to read it.

Experimenting With Food

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Once upon a time, many years ago, I packed myself a peanut butter and broccoli sandwich for lunch and brought it to work. Peanuts are legumes, just like chickpeas, I reasoned, so I had a reasonable basis for thinking that swapping out hummus for peanut butter would taste good. Not only was I wrong, but the sandwich was horrendous and bordered on inedible.

When I recently reminded Joanne about my experiment gone wrong, she was unsympathetic, insinuating that I was nuts for inventing such a strange combination of foods. Some of her own food experiments have turned out poorly as well, but she defended them by explaining that she has generally gotten her ideas from TikTok and elsewhere on social media. But someone out there was the first person to try each of those ideas, I explained, and they had to have the flexibility and imagination to try something new before discovering that they liked the result enough to post about it for others to see. If my peanut butter and broccoli combination had turned out great, I would have told other people about it, and maybe it would have become a thing.

Just as the results of experimenting with food are all over the place, so are the reasons for trying new combinations in the first place. Out of mayo earlier this month, Joanne made tuna salad with yogurt, and the tangy result was terrible. Unsure what to do with leftover Halloween candy corns a couple of decades ago, I put some on top of mint Oreo ice cream, and I loved the weird combination so much that I have made it every fall for the last 20 years. After finding that her breakfasts were not holding her for very long, Joanne tried adding Orgain powder to her coffee and cottage cheese to her eggs, and the increased protein leaves her satiated for a longer duration. Because I wanted to increase my fiber intake, I tried marinara sauce on chickpeas and found that I like it just as much, if not better, than on pasta. On paper, drinking soda during endurance events is a questionable choice, but after some experimentation with different hydration options, I set my marathon personal record on Coca-Cola Classic. Without allowing her to experiment, we never would have learned that one of our daughter’s favorite drinks is pickle juice.

While necessity sometimes leads to new creations, imagination is often a driving force, but creativity means little without the freedom to experiment. If you have food rules, consider how they are affecting your ability to experiment with food. While I am not advocating for food rules, I do acknowledge that they can have some upside. For example, someone who feels that they must have a vegetable with dinner may feel inspired to try a wide array of vegetables for the sake of variety and keeping things fresh within the limitations that their food rule demands. On the other hand, one of the many downsides of food rules is that they limit the scope of creativity. For example, the aforementioned individual who insists on having a vegetable with dinner has fewer options than someone who is flexible regarding a vegetable’s inclusion. Given that, if you have food rules, consider downgrading them to food guidelines in order to give yourself more freedom.

If you put food rules and norms to the side and give yourself permission to put your creativity to work, what might you try?

The Lingering Effect of Scarcity

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Cleaning up the house earlier this week, I came upon a bottle of hand sanitizer that was functionally empty, as the remaining liquid was too shallow for the pump to reach. If I had found it in 2019 or earlier, I would have dumped out the little bit of sanitizer and recycled the bottle without even considering any other option. But that was before COVID-19, before cleaning products became precious commodities, before I went from store to store in search of them only to find empty shelves, before opportunists were reselling them online for ten times their sticker prices, and before a friendly pharmacy clerk discreetly slipped me a pocket-sized bottle of sanitizer as though she was passing off a top-secret document in a spy movie.

After all of that, even four years later, no way could I bring myself to waste any amount of hand sanitizer. And really, that comes as no surprise. Several decades after the Great Depression, my grandparents still could not bring themselves to leave any food uneaten, so much so that they once finished Chinese food leftovers despite knowing that my brother and I had found a boiled insect in the rice.

As I was doing my best to transfer the remaining hand sanitizer to another bottle without spilling a drop, I thought about patients of mine who are still working to recover from food scarcity that ended many years ago. Remember, food scarcity has several etiologies, including famine, financial hardship, political blockades, food deserts, and limitations imposed by oneself or by someone else. Intellectually, we know the difference between going hungry because flooding destroyed this year’s crop and putting a cap on our eating because we are on a diet, but on a biological level, all our bodies know is that they are not getting what they need. When the restriction ends, we are driven to get as much as we can of what we missed for fear that another period of restriction will come.

The solution is indefinite abundance. The more we surround ourselves with food, especially ones that were previously restricted, and the more we reaffirm that we are done with self-imposed limitations, the more the drive to overconsume decreases. (Side note: Overeating can have several different roots. Here, I am referring specifically to overconsumption that comes from restriction.) If someone finds that a specific food is particularly a trigger, the stocking technique might be helpful.

Certainly, the concept of abundance entails a great deal of privilege, such as access to foods, money to buy them, and places to store them. Some of the factors that influence access are beyond our control. To the extent that we are able to give ourselves consistent and ongoing access to a wide variety of foods and pledge that the days of restricting ourselves are over and never to return, we help to curb the frenzied drive for more and more.

And of course it takes time, maybe even a long time, to shake scarcity’s impact. Understandably, we want to reach a more peaceful relationship with food sooner rather than later, but there is no way to rush the process. We just have to be patient, ride the wave of everything that comes up along the way, and continually remind ourselves that we will always do our best to maintain our access to hand sanitizer – I mean food – going forward.

A Con Or A Pro?

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At some point in my clinical training, I learned the basic guideline, “When the gut works, use it.” In other words, do not utilize TPN (intravenous feeding) if the gastrointestinal tract is healthy enough for at least enteral (tube) feeding. If the latter is called for, depositing into the stomach rather than the small intestine is better, if medically possible, in order to utilize as much of the gastrointestinal tract as possible. If the patient can eat by mouth, even better.

Working in an outpatient setting, I use meal plans similarly to how clinical dietitians utilize TPN. Both are treatment options that have their place, but better to avoid them if possible. Whereas clinical dietitians resort to TPN only when the patient’s gastrointestinal tract is not functioning well enough to rely on other options, I use meal plans only when a patient’s ability to make sound eating decisions on their own is significantly compromised, as can be the case when one is in the early stages of recovering from a restrictive eating disorder.

In these situations, meal plans can help in a multitude of ways. By making some of the decisions regarding what, when, and how much to eat, meal plans streamline the choices that patients have to make themselves. Rather than patients and their parents arguing over meal compositions and quantities, they can refer to the meal plan, thereby reducing the strain that eating disorders can place on families. When followed, meal plans provide enough nutrition for the body to rebuild itself and hopefully keep the patient out of a higher level of care.

Despite these upsides, meal plans also have their downsides, one of which is that they simplify nutrition to a fault. Rather than specifying what a patient is supposed to eat at a given time, meal plans typically utilize an exchange system that allows the patient to select the foods that fit the indicated criteria. For example, one patient’s meal plan might say to have one protein and one grain at snack time, so then the patient would survey the provided list of foods that qualify as proteins and their respective quantities and decide which one to have, and then they would make a similar decision about which grain to have.

The problem is the oversimplified rounding off necessary in order to force foods with complex nutrient profiles into these basic categories. For example, we classify chickpeas as a “protein” when in reality only approximately 23% of their calories come from protein and 10% and 67% come from fat and carbohydrate, respectively. How does that make sense? Cashews are 19% protein, 42% fat, and 39% carbohydrate, but our exchange list says a patient can count them as a protein or a fat. Huh? We treat all cooked vegetables the same even though spinach is significantly higher in protein than carrots are (48% versus 8%, respectively) and much lower in carbohydrate (41% versus 89%, respectively). What?

But is this oversimplification really a flaw? Consider that many (but certainly not all) patients with restrictive eating disorders are high achievers with perfectionist tendencies, and their disorder drives them to seek out and consume exactly what and how much they believe they are supposed to eat. Part of their recovery entails helping them to understand that a drive for perfection, which might be an asset in some realms of life, is unnecessary and counterproductive when applied to eating.

The human body is adaptable and can thrive under a variety of eating conditions. Some populations rely heavily upon starches, fruits, and vegetables, while others get by subsisting on fatty meats. Looking at our country’s own nutrition guidelines, the recommended ranges for protein, fat, and carbohydrate are quite wide. For example, the acceptable macronutrient distribution range for carbohydrate is 45% to 65% of one’s total energy intake, which is quite broad.

Barring certain medical conditions, we do not need to be exact in our eating in order to provide our bodies with the nutrients they need. In that sense, whether we classify chickpeas as a protein or a carbohydrate, or cashews as a protein or a fat, etc., really does not matter; the body will still receive the nutrition it needs regardless. So, while we could view such oversimplifications as cons, I see them as pros, as they teach and reinforce flexibility and freedom in eating, which are important aspects of recovery, rather than rigidity and precision.

Working With a Running Coach: Why I Started, Why I Stopped

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In February 2019, I had one of the best racing performances of my life. My finishing time was just shy of the personal record that I set 12 years earlier, and had I better understood the course, I think I could have beaten it. Despite my age and three surgeries in the preceding five years, I was still running close to my best. Then, for reasons that I still cannot completely identify, my running ability abruptly fell off a cliff.

Sometimes I have dreams in which I struggle to run, like I am knee-deep in molasses, and this struggle became real in the summer of 2019. My legs were not tired, nor were they sore, but they just would not go. It was the oddest feeling, and the best way I can describe it is to compare it to having a limb that has fallen asleep: There is nothing structurally wrong with it, but it just does not work as it should. One morning, Joanne watched from the front door as I slowly jogged down to the end of the block, stopped, threw my hands up in exasperation and frustration, and walked back home.

From the summer of 2019 to early 2023, my running rebounded to a small extent. My endurance returned but my speed did not when I ran another marathon in 2022. In fact, my speed continued to worsen over those years at a pace that getting older alone does not explain. Each time I had an inexplicably slow run, each one seemingly slower than the preceding outing, my confusion and frustration grew and began to morph into disgust. In the midst of these runs, sometimes I thought about stopping – not just that day’s workout, but giving up running entirely.

After hearing of my frustration, a generous friend gifted me three months with a running coach who works remotely with distance runners all around the world. During our first conversation, the coach offered his opinion that I was running too fast during most of my training runs. Running slower in order to run faster sounded counterintuitive, but I was willing to try his approach for a few reasons. One, the training approach I had been taking clearly was no longer working for me. Two, he had helped numerous runners – including my friend – dramatically improve their running, which gave me hope that he could do the same with me. Three, in my line of work, I am used to offering suggestions that seem counterproductive at first glance, such as stocking, so I know to keep an open mind.

The coach used the workout pattern that I was already following as a starting point, but he made some significant changes. He added an additional day of running per week, increased my mileage, and significantly slowed my pace. Even during my interval workouts, he wanted me to refrain from running as hard as I could.

He gave me a training plan to follow, and while the specifics varied from week to week, the overall pattern was the same. Tuesdays were interval workouts at the track, Thursdays were recovery runs, and Saturdays were long and slow jogs. At first, the workout’s distances and paces were easy for me to achieve, which gave me confidence that I would be able to keep up with the coach’s training plan, and I felt optimistic.

Then problems arose. While I never got injured under the coach’s watch, I began getting sick more often than I ever had in adulthood. The frequent illnesses were more correlation than causation, as I suspect they were mostly due to exposure to the germs that our daughter brings home from kindergarten. However, I was pushing myself too hard. Sure, my speeds were slower than what I would have run on my own, but I also pushed myself to achieve the workout goals even when I was overtired or otherwise not feeling up to it because skipping or modifying a prescribed workout felt like failure. Instead of sleeping relatively late on Saturday mornings, I was waking up and starting my runs in the dark in order to fit in the mileage before beginning daddy duty. Between the decreased sleep and pushing myself too hard in my training, I was wearing myself out.

Still, I kept going, as I was clinging to the hope that following the coach’s training plan would make me a better runner, just like he had done for others. A few months into our training plan, coach began to prescribe faster workouts. After running so slowly for so long though, the goal paces felt lightning quick, and I failed to achieve them. At the beginning of our work, I routinely returned home from my training runs feeling optimistic, happy, and proud that I was able to achieve the goals that coach set out for me, but soon failure became the norm. Before leaving my house for a training run, I looked at the prescribed workout knowing I would need a miracle to achieve the day’s goals. Instead of feeling positive, I felt guilty and ashamed, and I wondered what was wrong with me.

Coach and I ended up working together for somewhere around six or seven months before I called it quits. He is a super nice guy, an elite runner himself, and he has vast coaching experience, loads of knowledge, and a long list of runners he had helped, but I seemed to be some sort of outlier in that my body was not responding positively to his training plan. We seemed to be bumping up against whatever mysterious factors had eroded my running abilities in the first place.

As you have read through my story, I wonder if you have picked up on the common themes between my work with the running coach and diet culture: turning to someone who “looks the part” for guidance, optimism based on testimonials that may or may not be indicative of typical results, reliance on external prescriptions rather than internal cues, and self-blame in the face of failure. Ultimately, realizing these commonalities is why I stopped.

Now I take a similar approach to running that diet survivors do to eating. My body’s internal cues are the primary factors in the decisions I make regarding when, how far, and how fast to run. Instead of focusing on my slow speed and feeling frustrated about it, I am working on accepting that all bodies change over time and the amount of control that I have over mine is limited. These days, I try to approach my running with a spirit of enjoyment and adventure, a fun and relaxing way to be outside, and feeling proud about covering ground on my own two feet – even if they do move much slower than they once did.