So, what exactly do future dietitians do at a dietetic internship?

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Just a few months after passing my exam to officially become a registered dietitian (RD), one of my former professors asked me to come back to the University of Massachusetts Amherst (UMass) to talk with some of her nutrition students about my training and the process of becoming an RD. At one point, she asked me to talk about my dietetic internship. While I have no idea what I said, she could tell that I was holding back, and she interjected and assured me it was okay to be candid. So I gave it to them straight: My internship was the worst year of my life.

Before I get to why the experience was so horrible and what I learned during it, first let me introduce what a dietetic internship is and how it fits in with a budding RD’s training. Somewhat similar to a medical residency, a dietetic internship is a bridge between school and becoming a full-fledged healthcare practitioner. Unlike school, where students study concepts in an academic setting, internships provide hands-on opportunities to perform the roles of a dietitian while under supervision. Only after finishing their schooling can one begin an internship, and only after satisfactorily completing their internship can one sit for the exam to become an RD. The internship, in another words, is a required step in the career path.

Applicants indicate the programs they are interested in and rank them in order of preference, the internship programs themselves similarly rank their applicants, and then a computer figures out the matches. Placement in an internship is not a guarantee – one statistic that I read estimates that only 60% of applicants each year are matched to an internship –  and I remember classmates who applied multiple times without ever receiving a match. No internship means no career as a registered dietitian, a reality that I feel should have been mentioned at the beginning – rather than towards the end – of nutrition school so students would have adequate time to formulate a plan B. The computer matched me to Boston’s Beth Israel Deaconess Medical Center (BIDMC), which I had listed as my first choice.

Internships typically include rotations in clinical care, community nutrition, and food service settings, but the exact composition varies from program to program. For example, one of the internships I know of has an added focus on business while mine emphasized medical nutrition therapy. Each setting includes multiple rotations that give an intern a chance to perform a variety of duties in a range of settings. Most of my rotations took place at BIDMC, but some were off site in the surrounding community.

 

Food Service Management

My internship began with a rotation in food service management, which had me working in the hospital’s cafeteria. My tasks ranged from culinary duties, such as learning how to efficiently chop vegetables and then applying these skills by dicing about 60 pounds of winter squash, to studying the technical specifications of various pieces of industrial kitchen equipment. At no point in my career have I ever needed to know the details of the Alto-Shaam Combitherm Model 12-18ESG flash-steam combination oven/steamer, but for a few weeks of my life, I could have told you all about it.

They told me to spend an hour working one of the cafeteria registers. After about 45 minutes, I had developed a whole new appreciation for cashiers and the pain and degradation that they tolerate. While ringing up purchases and processing payments was straightforward, the boredom and rude customers led me to conclude that there is no way I would last long doing checkout.

One of my tasks was to design and implement a nutrition promotion in the cafeteria. For whatever reason, I chose lycopene, a chemical compound found in some fruits and vegetables, so I put together table tents, a PowerPoint presentation that I projected on a cafeteria wall, and other educational materials for our customers. Additionally, I created special menu options high in lycopene, such as stuffed red bell peppers and cherry tomatoes, to coincide with the day.

While I enjoyed the food service courses that I took in nutrition school, my food service management rotation was unpleasant and awkward. In no way do I look down upon people who perform manual labor, nor am I above doing such work myself; when I worked as a personal trainer, I spent extra hours at the gym washing towels, mopping floors, and wiping down equipment, and I found pride, enjoyment, and satisfaction in maintaining a clean and orderly environment for our members. But the interpersonal dynamics at the hospital were based on a hierarchical structure, even in the kitchen, which suggested not so subtly that some jobs – and therefore some people – were more important than others when in reality they are all necessary for the hospital to properly function. Shadowing a line cook for a few hours so he could teach me about his job before I moved along to more “important” duties while he continued to make food felt like disrespectful cosplay, which did not sit well with me.

Being an intern, I was considered pretty far down the pecking order myself. On the day of my special menu, my preceptor got mad at me because the menu ingredient list read cherry tomatoes while the dish that she assumed was mine contained chopped tomatoes. As she was laying into me, I realized that the discrepancy involved a different dish, one that was not part of my special, and the ingredient list for my entree was in fact accurate. She did apologize, but the incident illustrated her general attitude towards interns and her employees, which was to pass judgment before having an understanding of a given situation or behavior and to hold a default presumption that those under her were inept.

 

Patient Food Service

Lucky for me, my patient food service rotation was at a different BIDMC campus, and my preceptor this time around was great. She welcomed questions, invited my input, and even gave me her home telephone number so I could call her while she was out of the office if I needed something.

My duties included putting together patient meals, checking the trays against their order forms to ensure accuracy, and delivering the food. The room service associate – the job title for the people who deliver food to patient rooms – that I shadowed was great and demonstrated how to appropriately address the patients. Knock on the door, even if it is wide open, to alert the patient that someone is coming. If a medical professional or a visitor is present, discreetly and quietly leave the tray on the bedside stand. Otherwise, greet the patient and quickly leave unless they have questions or comments. Such guidelines may or may not seem obvious, but as someone who had never worked in a hospital before, I was grateful that she took the time to teach me proper etiquette.

As an intern, I was required to dress business casual and wear a white lab coat no matter what I was doing, even when I was delivering trays. Consequently, patients often seemed confused when I walked in wearing a lab coat and carrying a tray of food. On at least one occasion, someone mistook me for a doctor. The confusion was so immediate that some patients were already perplexed by the time I could identify myself as from the food services.

While working in the “nourishment kitchen” processing and preparing patient supplement orders, I sampled each supplement myself on the advice of my supervisor, as she felt that it was important for me to have tried them so that I could relate to the patients who needed to take them. Patients occasionally asked me for advice regarding which supplement flavor to choose, and I also noticed their moods improve when they complained about a given supplement and I was able to empathize because I had tried the same drink myself. Had I not sampled the supplements, these quality patient interactions would not have taken place.

Another series of taste tests involved ordering trays for myself as I tried to put myself in the position of patients who were on special diets. Selecting a complete and satisfying meal while satisfying the constraints of a strict sodium restriction was difficult, almost as challenging as consuming pureed turkey and broccoli and thickened orange juice.

One of my tasks was to interview 20 patients on various hospital floors about the food. The opinions tended to be a matter of perspective. Generally speaking, those who evaluated the BIDMC food in relation to other institutional food spoke very highly of it, while those who compared it to restaurant food were typically disappointed. While I found it interesting to hear what patients had to say about the food, the part of the experience from which I learned the most was simply talking with them. As one patient told me when I asked him about the food, “I have bigger things to worry about than the food,” pointing to a surgical scar and tubes protruding from various places in his body.

 

Clinical Care

Shortly after finishing my internship, I called a colleague whom I had met during the experience to discuss the next step in my career. Referencing the tradition that new dietitians are supposed to pay their dues by working in a clinical setting before moving on to other areas of employment, I told him, “I know I am supposed to work in clinical, but . . .” “Stop right there,” he said, cutting me off. He went on to explain how outdated and nonsensical this tradition is, as clinical work has little to do with other areas of nutrition. He was right.

The three things I like to do that are the reason I decided to pursue a career in dietetics are getting to know patients, talking about food, and facilitating long-term behavior change, yet rarely does a dietitian do any of them in a clinical setting. Forget getting to know patients, as mine were often asleep, sedated, or otherwise unable to communicate, and my interactions with them were typically limited to entering their rooms and gathering whatever data I needed from their bedside medical devices and their chart notes. Forget talking about food, as my patients were frequently unable to eat and were instead relying on nutrition via enteral (i.e., a tube or port into the gastrointestinal tract) or parenteral (i.e., a line directly into the blood stream) feedings. And forget facilitating long-term behavior change, as the goal was almost always just to get the patient well enough for discharge.

My clinical rotations took place at BIDMC, Boston Children’s Hospital, Somerville Hospital, and the Youville Hospital and Rehabilitation Center. The only memory that stands out to me regarding the last two rotations is that I remember eating lunch with one of my preceptors and commenting that I appreciated her sitting with me, as we were specifically told not to eat lunch with the BIDMC clinical dietitians, who did not want to sit with their interns. She told me that those dietitians should be embarrassed and ashamed of themselves.

Generally speaking, my duties at BIDMC, whether I was in the ICU, the transplant ward, or another unit, entailed gathering data from a patient’s medical chart – particularly their lab work – and then using it to make recommendations regarding their nutrition prescription. Patients who were eating, but still needed some nutrition support, typically saw a diet technician, who could offer some suggestions regarding supplements, such as Ensure. In contrast, RDs and we dietetic interns treated sicker patients who were usually not eating and instead needed the aforementioned enteral or parenteral (TPN) methods of nutrient intake. TPN formulations often required daily tweaking depending on a patient’s labs, so I would look at their blood results, come up with my recommendations, run them by my preceptor, and then call down to the pharmacy and direct them as to how to construct the composition of that patient’s TPN mix for the day. Sometimes I also made recommendations for supplementation, like banana flakes for a C. diff infection or zinc for a pressure ulcer. This is where I learned that giving too much zinc for too long can create a copper deficiency, as the two minerals compete for absorption.

Some specific moments stand out in my memory, such as the time I was present for a tracheotomy, which was way bloodier in real life than on television. As I was backing away from the patient for fear that I was about to faint, the doctor told me, “Don’t be shy, get right in there!” Another day, I arrived to find the unit abuzz with many of the nurses and residents giggling and talking quietly to each other. After asking around, I learned that they were readying to squirt warm maple syrup up a patient’s butt.

Other standout memories are humorless, like the time I was working in the ICU and went to assess a patient, but their nurse told me not to bother, as they were unlikely to survive the day. The last patient that I ever treated while I was an intern had terminal cancer and was barely eating. She quietly responded to my suggestions, none of which would have made any sort of meaningful difference. They never prepared us for how to respond to death or to talk with patients who were on its verge and their families. We were left to come up with the answers ourselves, and I am quite certain mine were lacking.

My rotation at Boston Children’s Hospital was perhaps the most miserable stretch of the internship, largely because I was directed to treat patients right off the bat before I felt I had a solid enough understanding of pediatric care. The dietitians acted like we interns were an annoyance and a disruption to their work – which, granted, we probably were, but that was not our fault – and questions often did not go over well. My preceptor seemed generally bitter about her situation, as she really wanted to be a doctor, but settled for becoming an RD because she did not think she could handle medical school. Her story was not unique, as I met quite a few dietitians working in clinical settings who wanted to be doing something else. It reminded me of freshman orientation at Tufts University, a place to which I had applied early action because it was the only college I wanted to go to, and I was surprised by how many of my peers were disappointed to be there, as Tufts was their safety school that they had to fall back on after failing to get in any of the Ivies.

As was the case in nutrition school, we got very little eating disorder training during the internship. One of my rare exposures occurred at Children’s, as I remember shadowing a dietitian who was gently trying to convince an anorexic girl to drink some milk. The girl – wearing a thick sweatshirt because her body’s metabolism had slowed so much that she was not producing adequate heat – was bawling.

A major source of my frustration was writing chart notes. The documenting itself, which at this time was still typically done by hand, was not the issue. Rather, the problem was that each of my preceptors wrote notes differently, yet each of them felt strongly that their way was the singular right way. Each time my clinical preceptor changed, they would initially be disgusted by my notes, and by the time I adjusted and was documenting to their liking, it would be time to switch preceptors and the cycle repeated. For example, one of my preceptors co-signed one of my notes and told me “very good.” My next preceptor looked at that same exact note and told me she would not have agreed to sign it. Then I modeled my notes after her own, but my next preceptor looked at them and tore them apart, including calling them grammatically incorrect, which they certainly were not. Sometimes they allowed me to cross out and initialize the words or passages they wanted rephrased, but they were not always so generous. One time, I remember having to stay late to copy over an entire page-long note because my preceptor took issue with literally one word. “Different” is not synonymous with “wrong,” but try telling that to these people.

Furthermore, now that I am a practicing dietitian, it turns out that how I write my notes does not matter. Nobody cares. The insurance companies who occasionally request my notes as part of their decision-making process for determining coverage do not care, and the doctors – who rarely read the notes that I send them – definitely do not care.

Criticizing our note-writing skills was just one of their ways of giving us a hard time and treating us as less than. The BIDMC clinical units had a class system with doctors at the top of the hierarchy, RDs somewhere behind nurses (hence the derogatory nickname for dietitians, “Jello ladies”) and dietetic interns even lower. Having a power structure makes sense in some contexts – if a patient codes, knowing who is in charge and what each person’s responsibilities are streamlines care and saves precious time – but other times it is counterproductive. Pushing people down is a lost opportunity to gain their insight, which in a healthcare setting means worse patient care. One of my fellow interns described our experience as being similar to pledging a sorority, and just like with pledges joining Greek life or rookies on a sports team, hazing and treating the new folks with disrespect has never made any sense to me.

Around the time of my rotation at Children’s, I realized how depressed I had become since starting the internship, particularly its clinical portion. My morning commute consisted of taking the 51 bus from my West Roxbury apartment to Reservoir, then taking the green line to the Longwood Medical Area, and it got to the point where I legitimately hoped my bus crashed so I did not have to go to work. Rationally, I knew that of course the internship would eventually finish, but my heart felt differently, as I could not see myself making it through to the end. It was at this point that I knew I needed therapy.

 

Outpatient Counseling

After my clinical rotations were over, things began looking up. A new calendar year began and suddenly the internship’s June end date felt attainable. Around this time, I also met Joanne. (People assume we met through dietetics, but that is not the case; it was just coincidence that we were both in the same field.) Also of significance, this is when my outpatient counseling rotations – which were my favorite rotations of the entire internship – began. For the first time in a long while, I could see the light at the end of the tunnel.

In my medical nutrition therapy rotation, I worked closely with BIDMC’s outpatient dietitian, who counseled patients with cardiovascular disease, diabetes, liver disease, and other ailments. One of the aspects of this rotation that I most appreciated was that I had a chance to observe her before I began to counsel patients myself. Given that I only had one counseling course in nutrition school, I valued the chance to learn more, especially from someone as seasoned as she was. It was from her that I learned that a dietitian can be simultaneously informal and professional, that keeping the vibe of an appointment relaxed can help patients feel more at ease.

When we were not in the clinic, we went out into the community on a roving healthcare van that stopped in some of the more impoverished areas of the city. We gave out condoms, took blood pressure readings and blood sugar checks, and answered nutrition questions for anybody who stopped by, all for free. The only specific nutrition discussion I can remember having with someone pertained to the sodium content of her favorite spice mix. During our breaks, my preceptor took me around the neighborhoods to visit restaurants, food pantries, and grocery stores. We talked with some of the regulars who relied on the pantries, and I was struck by the realization that food insecurity is not some abstract notion in textbooks or a relic of a bygone era, but rather a present challenge for many people in our own city.

One of my other outpatient rotations was with a BIDMC dietitian who specialized in Celiac disease and food allergies. As part of this rotation, I – along with one of my fellow interns – wrote the elimination diet manual that BIDMC went on to use, although I imagine they have long since replaced it with an updated version.

The bariatric clinic had two outpatient dietitians that I shadowed for a week, but I remember little of what went on there. They arranged for me to observe a lap band fill, and I also remember watching a Roux-en-Y bypass surgery being broadcast live to a monitor outside the operating room. One specific memory I have is of waking up and realizing I had just fallen asleep while sitting in on a counseling session. Both the dietitian and patient noticed. I was super embarrassed, but they were kind about it. After the appointment, the dietitian gently told me that I needed to figure out how to get more sleep. An aspect of the internship that I had not anticipated was just how much work we would have to do after hours. Typically, I woke up early, spent the day at the hospital – or wherever my particular rotation was – went to the gym, then stayed up very late reading, researching, or doing whatever other tasks I had to handle. The hours were certainly nothing like the legendary marathon shifts that medical residents work, but they were exhausting nonetheless and took a cumulative toll.

For another week, I got to spend time shadowing dietitians at the Joslin Diabetes Center. This was a fantastic experience. The nurses, doctors, exercise physiologists, and dietitians treated each other with a level of mutual respect that was absent at BIDMC. The staff did an excellent job of putting themselves in the patients’ shoes and empathizing with how scared and confused some of them were. Counselors often spent extra time with them and told them to call or email anytime with additional questions. This is how outpatient counseling is meant to be, I thought, and I have done my best to follow their example.

 

Research

Given my experience and interest in research, I was looking forward to my rotation in BIDMC’s general research center. We implemented the eating protocols for whatever nutrition-related studies happened to be taking place there at the time. One morning, they let me try the metabolic hood, an indirect calorimetry device that covers the subject’s head like a motorcycle helmet and uses their oxygen intake and carbon dioxide output to estimate their resting metabolic rate.

A few months after the internship was over, I applied for and subsequently accepted a research position at another general research center in Boston. Before starting the job though, I came to realize that while I do like research, it is not my passion, and my heart was really in counseling. I felt awful rescinding my acceptance, as I knew I was putting the research center in a tough spot and harming my own reputation, but it was the right call.

 

Plan-Your-Own Rotations

For two weeks, we were left to plan our own rotations in subject areas where we wanted additional experience. Having performed statistical analyses for a professor in the Tufts University nutrition school when I was an undergraduate at the university, I reached out to her to see if I could do any similar work for her as one of my plan-your-own rotations. Looking back at my files from the rotation, I see a bunch of charts and graphs that I put together for her, but I have no idea what the subject matter was.

Given my background as a personal trainer, I wondered if I might have a future working at a health club doing both training and nutrition counseling, so I sought out a dietitian who had that exact job and shadowed her as my other plan-your-own rotation. Two specific memories stand out to me. The first was when she offered to counsel me, just as she would one of her clients, so I could get a sense of how she practiced, and she food shamed me for eating dessert. The experience made me realize how harmful judgment is and how fear of it can understandably inspire patients to misrepresent their eating as a defense, as I was certainly tempted to lie to her going forward after seeing how she reacted to my reported dessert. The second stand-out memory is of an argument she had with a woman in one of her group fitness classes. The woman insisted that she was following the meal plan that the dietitian had given her, while the dietitian insisted that she was lying because if she was truly following the meal plan, she would be losing weight, which she was not. The argument was uncomfortable to witness, and I felt badly for the woman. When I later learned about Health at Every Size, I remembered this argument as an example of the trouble that can arise when we think we have more control over body weight than we actually do.

 

Community Nutrition

One of my community nutrition rotations was with ABCD Head Start. Unfortunately, I have absolutely no recollection of this experience other than seeing one of the workers get reprimanded for bringing Reese’s peanut butter cups into the nut-free facility.

The other rotation was with Boston Public Schools. My main tasks were to create educational materials, such as bulletin board materials and newsletters, for students and their families. The administrative office was a very casual environment, and I remember my preceptor and her colleagues giving me advice regarding how to approach Valentine’s Day with Joanne, as they felt I had to walk a fine line between not being dismissive of the holiday yet not coming on too strong given that we had only been dating for about a month at that point. Like a true intern, I was sent to get coffee for my preceptor, who once playfully slapped me for writing material for a bulletin board by hand instead of printing it out.

 

Class Days

We spent Tuesdays through Fridays at our rotations, but Mondays were our class days. The eight of us BIDMC interns would get together – sometimes by ourselves, and sometimes with other interns from the area – to spend the day learning about a given subject. We spent one day learning about mindful eating (which, by the way, is not synonymous with intuitive eating, although I suppose that is a topic for a different blog) and another about pediatrics. A dietitian from Gatorade came to talk with us about sports nutrition. One of the hospital’s gastroenterologists taught us about, well, gastroenterology. We spent a day at the Army’s research facility in Natick learning about field rations. The other class day topics escape me, but there were certainly more.

Along the way, each of us had to give presentations of our own to the class. Inspired by my visits to Native American reservations during my cross-country bicycle ride, one of my research projects looked at the dietary patterns of the residents of these reservations. Another one of my research projects looked at how other populations around the world treat constipation, which is how I learned about Pajala porridge and that people in the southern hemisphere use kiwifruit the same way that we use prunes. Looking at my notes, I see that I had started research for a presentation on competitive eaters and how they are able to hold so much food in their bodies at once, but apparently I abandoned the topic for some reason. One of the other interns and I gave a joint presentation on VACTERL association, which I had to Google just now to remember what it is.

 

In the end . . .

This has been a difficult blog to write. Generally speaking, these are not happy memories. The stress, the exhaustion, and the frequent disrespect made for a difficult year in which I did not learn as much about nutrition as I expected.

Additionally, I was angry – mad at the internship for not being what I wanted it to be, and mad at myself for putting myself in this situation. During the application process, internship directors were telling me that due to my strong resume and being a minority in a female-dominated field, I could go to any internship that I wanted, that it was up to me to decide where I wanted to be. Because of the geographic constraints I put on myself and by process of elimination, I ended up at BIDMC, which was supposedly one of the most prestigious programs in the country, but in hindsight, it was not the right one for me.

At the same time, I hesitate to go so far as to say I regret having gone there. Changing any element of the past would result in a different present than the one I have now. As I stated both before and during the internship, I wanted to be an outpatient counselor, and now that is what I do. While I might not have enjoyed my time at BIDMC, it is part of the route that got me here.

So, what exactly do future dietitians learn in nutrition school?

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Our switch from holding in-person appointments to telehealth has yielded many benefits, one of which is that now nobody can see the various diplomas and certificates that are mounted on my office wall. Having these documents on display makes me somewhat uncomfortable, as it feels a bit like bragging, which is why I only put them up after some patients suggested I should. Looking at them recently, I began to wonder what these framed pieces of paper mean to the people who wanted to see them. In essence, they are just souvenirs from my education, so perhaps interest in them is really just indirect curiosity about my training. So, what exactly do future dietitians learn in nutrition school? The specifics depend on where and when they study, but if my experience is any indication, it probably looks something like this.

The Basics

As an undergrad at Tufts University double majoring in mathematics and English, I had little room in my coursework for science classes. Given that, before I could begin to directly study nutrition at the University of Massachusetts Amherst (UMass), the department required that I take some prerequisites. Therefore, my nutrition schooling started from the very beginning with the most basic biology, chemistry, and physiology courses.

Of these three disciplines, the greatest focus was on chemistry. We had two semesters of general chemistry followed by two semesters of organic chemistry and one biochemistry course, all of which had lab components. When I last studied chemistry in high school, I found it difficult to understand and I consequently struggled. With that being my history, the prospect of having to take these relatively advanced chemistry courses was so intimidating that I nearly backed out of the program on the eve of my first day of classes because I was doubtful that I could succeed. Instead, I plunged myself into the subject. Motivated by intense fear and intimidation, I did everything I could to survive. No matter how well I did, I figured failure was just around the corner, so I had better keep the pedal to the metal. In addition to regularly attending office hours, I went to the on-campus tutoring department for extra review. In my free time, I answered every question in the textbooks, including ones that were not assigned. At the peak of my anxiety, I even sat in on chemistry classes I was not enrolled in just so I could hear the material discussed again and again and again.

In the end, the university gave me a merit scholarship for being one of the top three organic chemistry students out of approximately 600. Given my history with the subject and how hard I worked, receiving this award was one of the proudest achievements in my life. However, all that knowledge has played virtually no role in my work as a dietitian. Sure, I can explain the chemical structures of sugar alcohols and omega-3 fatty acids, why some fats are solids at room temperature while others are liquids, and how a bomb calorimeter works, but these skills make me no better of a clinician than a colleague who cannot do these things. Hopefully, chemistry requirements have scaled down in the years since I was a student, as my curriculum could have easily included less chemistry without negatively affecting my abilities as a practitioner.

Food Service

If you had no idea that many dietitians end up working in food service management, then you are in good company, as I had no idea about that either before I started nutrition school. To prepare us for this possible career track, the department had us take two courses in the hotel, restaurant, and travel administration (HRTA) program and two more in the management school.

Sometimes I contrast the difference between the random bits of information that have stuck with me from a course versus what I imagine those in charge of my education hoped I would retain. From the first HRTA course, I recall learning what a physical hazard is, how baby carrots are made, and that a successful coastal New England restaurant was thriving because of their choice of oven. All I remember from my human resource management course is working my ass off to show our professor – who warned us at the beginning of the semester that she does not give out As – that, actually, she does.

My second HRTA class made more of an impression, as it was a hands-on course that had us working in a semi-mock restaurant. We prepared and served real food to real customers, but no money changed hands because free food was their reward for being our guinea pigs. Joanne could tell you that whenever we meet someone who works in a restaurant, I pepper them with earnest questions that reflect my curiosity, such as how many eggs their diner goes through in a day. Given that, I thought this course was fascinating. We devised menus, planned theme meals, and rotated between all jobs in both the front and back of the house. Never having worked in a restaurant before, this was my first time being the target of the rudeness that some customers – even those who were eating for free and knew students were running the show – inflict upon those who wait on them.

Nutrition

And finally, the nutrition coursework itself began. The most basic class, Nutrition 101, was a survey class about the profession. This is where I learned that the term “nutritionist” has no legal definition, and anybody can call themselves one. The professor told us a story about someone who took an online test and received a nutritionist certificate – for their dog. One of my classmates announced to everybody that she was studying nutrition because she wanted to become a millionaire by inventing a fad diet.

Meal management and scientific principles, otherwise known as Nutrition 210, was an interesting course in that it included a lab component. Our experiments involved making several versions of a recipe and tweaking a variable, such as an ingredient or a preparation technique, to see how the changes affected the finished products. For example, we broiled, poached, and microwaved flounder fillets and then compared the texture and flavor of the cooked fish. We counted how many chews it took to sufficiently masticate pieces of top round sirloin prepared with a variety of tenderizers. My friend and I gave a group presentation on artificial sweeteners in which we compared popular myths versus what actual scientific research had found.

Nutrition 230 was a basic nutrition course in which we discussed the chemical structures, functions, and metabolism of various nutrients. Our professor told us that one of the reasons she chose a career in nutrition is because whenever she meets people, such as at a party, they are always interested in what she does. In contrast, many of our colleagues (including myself) try to conceal what we do for work because the follow-up questions – which are almost always based on myths and incorrect assumptions about our profession – can be frustrating and exhausting to answer.

A few years ago, I emailed my former Nutrition 352 professor, who has since been promoted to an associate dean, and let her know that my greatest regret from nutrition school is having sold my textbook soon after completing her life cycle nutrition course. Despite my two part-time jobs as a personal trainer and an assistant to the university’s food service dietitian, money was tight, and I felt I could use the cash more than a leftover textbook. Besides, I did not imagine that all these years later I would still be having occasions in which I want to refer back to it, yet that has turned out to be my reality. Fortunately, the Academy of Nutrition and Dietetics’ online Nutrition Care Manual contains a section on pediatric nutrition, which has somewhat filled the void, but I still wish I had that textbook.

Nutrition 572, community nutrition, is where I began to understand that food scarcity is not some abstract notion or one that only afflicted our ancestors and people in faraway lands, but rather one that is still a reality for many of our neighbors. One of our assignments was to go to the grocery store and design a diet that would nutritionally satisfy the Dietary Approaches to Stop Hypertension (DASH) diet while also financially satisfying the Thrifty Food Plan’s allowance of $4.37 per day. Even with my math background and nutrition knowledge, I could not do it, as the closest I could come was $4.77 per day, still $0.40 over budget. This course helped me to appreciate the impacts that financial limitations and food availability can have on health. The simple truth that people can only buy what they can afford and is accessible to them sounds so obvious now, but it took studying community nutrition for me to really get it. When I rode my bicycle from Seattle to Boston that summer, I made a point to visit the grocery stores on the Native American reservations that I passed through, as I wanted to understand the options available to the residents of these relatively isolated communities. Had I not taken community nutrition, I am not so sure I would have had the same level of curiosity.

In Nutrition 577, aptly titled nutritional problems in the United States, we studied the impact of nutrition on some of this country’s most common health concerns, such as cancer, diabetes, cardiovascular disease, and osteoporosis. Our professor was excellent, perhaps the best I ever had in nutrition school. She expected a lot from us, and she held herself to the same standard. She was also fat. While I did not judge her for her size, I remember perceiving that it was awkward for her – a nutrition expert in a bigger body – to teach us about “obesity.” Whether it was her or one of the other faculty of a similar build in our department, I cannot recall, but I do remember one of them explaining how difficult it was for them to be taken seriously because of their size. Many years later, this seed grew into a conference presentation I gave entitled “‘Looking the Part’: Patients’ Size-Based Biases Towards Their Practitioners and How to Handle Them.”

Medical nutrition therapy, Nutrition 580, was where the rubber met the road. We learned how to utilize the nutrition knowledge we had thus far accumulated and apply it to treating a wide variety of medical conditions. What stands out to me though are not the disease states we learned about, but rather some key ones that were omitted, namely eating disorders. Each of us had to research a disease (Mine was chronic pancreatitis.) and present to the class about it, and if not for another student’s brief presentation on anorexia nervosa, I would have gone the entire way through nutrition school having learned literally nothing about eating disorders. Maybe I am just biased because I now specialize in treating eating disorders, but it is hard for me to fathom that such an important group of illnesses that affect so many people was barely even mentioned.

Speaking of missing curriculum, the only counseling course we had was Nutrition 585. Of course, learning about the hard science of nutrition is important, but if dietitians are unable to effectively convey their knowledge to patients, then the information is moot. Before finishing nutrition school, I was already of the opinion that students (and therefore their future patients) would be better off if the required coursework focused less on the hard sciences, particularly chemistry, and more on counseling skills. My professional experience has only strengthened this stance.

My final course in the department was Nutrition 731, nutritional assessment. During my presentation on anthropometric predictors of cardiovascular disease, I demonstrated how hydration status introduces a source of error into bioelectrical impedance device readings that estimate body fat percentage by using such a device on myself at the beginning of my talk, then putting on a bunch of extra layers of clothes and giving the bulk of my presentation while riding an exercise bike, and then using the device again after having worked up a sweat.

Outside the Department

While taking the aforementioned nutrition courses, I also took classes in other departments, such as energy metabolism in the exercise science department. One of my takeaways from this class is just how difficult it is to design research studies that yield definitive answers. For example, our professor was confident that walking a mile and running a mile require the same caloric expenditures, but he could neither confirm nor reject this hypothesis because he could not design a study that would adequately control for all the confounding variables. He was also the first person to introduce me to the “fat-but-fit” concept, which is that someone can be both healthy and live in a bigger body.

The microbiology course I took in the food science department centered on foodborne illnesses. We learned about salmonella, staph, spores that survive cooking and freezing, and other scary things that to this day continue to make me think twice about some potential eating decisions. All these years later, I am still not brave enough to roll the dice with fried rice.

My psychology course was an introduction to the field’s basics with a focus on the nervous system’s structures and physiology. One of my takeaways was how important dietary fat is for maintaining the myelin sheaths that insulate our neurons and enable rapid transmission of electric impulses.

The nutrition program required some other courses that I was able to place out of due to my previous studies. For example, my English degree got me out of their nutrition and writing course, and my math degree similarly meant that I need not bother taking statistics. The child development course I took at Tufts enabled me to skip the same class at UMass.

Although I was fairly certain that I wanted to be a dietitian, I toyed with the idea of becoming a physical therapist, so I took some additional physics and anatomy courses that were prerequisites for physical therapy programs just to cover all my bases. Learning about anatomy was interesting, not so much because of the subject matter itself, but because it taught me the importance of speaking a patient’s figurative language. With my personal training clients most comfortable with colloquial terms like “chest” and “quads,” knowing the scientific names of hundreds of body parts proved fairly useless, and the knowledge soon escaped me.

Internship

Now you know what it took to earn the nutrition degree on my wall. One of the other significant documents that hangs near it is from my dietetic internship, which is somewhat like a future doctor’s residency and must be completed before dietitians-to-be can sit for their registration and licensing exam. Because this blog is already so lengthy that pretty much everybody has stopped reading by now (Hi, mom!), I will save discussing my internship until another time.

Continuous Glucose Monitoring

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“We start to, you know, numbers start to be overlaid onto everything like we’ve got some kind of headset on and we’re looking through it and there’s little value numbers attached to our foods and to the actions we take in our lives, and that’s tremendously unhealthy, I think, and can descend – you know, people I’ve interviewed and I’m sure people that you work with – can descend into pathology, right, where you’re constantly afraid that that equation is not right and you need to keep upping it and the output needs to be better and that you’re falling short. That’s not a good place to be.”

Dr. Alan Levinovitz, PhD, to Christy Harrison, MPH, RD, CEDS, in Food Psych #94

Earlier this month, a friend asked me about an email he received from a company trying to sell him a subscription to their continuous glucose monitoring (CGM) service. Since some of you are likely unfamiliar with it, CGM technology allows its user to automatically track their blood sugar levels around the clock. The monitor itself is a small sensor typically placed on someone’s abdomen or arm, and it contains a needle that measures sugar concentration in the skin’s intercellular fluid. A transmitter attached to the sensor sends the information to a separate device, such as a smartphone, on which the user can view their blood sugar data. As the American Diabetes Association discusses, CGM is a legitimate medical tool that diabetics can utilize to help manage their condition.

What was surprising about the email that my friend received is that the solicitor was not marketing their CGM service to diabetics, but rather to the general population. Their subscription service provides users with CGM devices, tools for tracking their food consumption, and access to a team of dietitians who analyze the data and help clients to examine the link between their eating and blood sugar levels. That may sound innocent enough, but I have concerns.

Their website (to which I am purposely not linking in order to avoid driving traffic their way) features enticing language like “Reinforce Good Habits,” “Promote Longevity,” “Manage Weight,” and “Gain Energy.” With approximately 51% of adults wanting to lose weight and some estimates claiming that 45% of the general population experiences fatigue, these calls to action seem designed for mass appeal. Their pitch continues, “While each journey is unique, we’ve found that remarkable improvement to your health and well-being can be achieved in just a single year,” and includes alluring testimonials, such as, “I was really in a place where I thought I kind of knew my body and I know what I’m feeling. I WAS WRONG.”

When I clicked on the “Get Started” link, the following page presented me with a multiple-choice question regarding my goals. This is the first of approximately a dozen questions, each on its own page, that opened up for me to answer. Between questions, a quote from one of their staff dietitians affirmed – based on my answer to the preceding question – that I was in the right place and they could help me. Using the back button, I changed my answers a bunch of times to see if I could produce a different result, one in which they would say their service is not appropriate for me, but that never happened. My impression is that they welcome everyone as a customer, which must make for a great business model.

Dangers exist in overemphasizing a single parameter of health and insinuating that everyone can benefit from focusing on it. While people may debate the quantity and identities of the various aspects of health, all of the models that I have seen agree that health is multifaceted. Depending on the particular model in question, categories may include emotional health, social health, and physical health, among others. Taking a closer look at physical health yields subcategories, such as anthropometric, biochemical, and clinical measures, and each of these has numerous parameters within them. Casting a bright light on one variable, such as blood sugar, while leaving the others in the twilight is an oversimplification of health, and to suggest that everyone – not just those with a known issue with their glycemic control – would benefit from doing so is at best misleading.

An overarching danger is that someone could pursue better blood sugar levels at the expense of other aspects of their health. For example, a user could adopt eating behaviors that may keep their blood sugar in check, but create or exacerbate issues with their cholesterol or blood pressure. Perhaps someone else begins to view foods that spike their blood sugar as “bad” and others as “good,” thereby bringing about or worsening disordered eating. Others may pursue better blood sugar at virtually any cost, eliminating or severely restricting certain foods, socially isolating themselves so they can eat exactly as they think they should, all the while feeling that what they are doing is not good enough and they need to be more diligent, thereby taking their disorder up a notch with each iteration.

Thinking about this CGM service reminds me of the debate surrounding full-body CT scans that some suggest could enable doctors to catch budding diseases in their infancy. Check out this 2017 Food and Drug Administration article, particularly the following quote, and note the parallel between the problem with these scans and what this CGM company is doing.

“CT is recognized as an invaluable medical tool for the diagnosis of disease, trauma, or abnormality in patients with signs or symptoms of disease. It’s also used for planning, guiding, and monitoring therapy. What’s new is that CT is being marketed as a preventive or proactive health care measure to healthy individuals who have no symptoms of disease. Taking preventive action, finding unsuspected disease, uncovering problems while they are treatable, these all sound great, almost too good to be true! In fact, at this time the Food and Drug Administration (FDA) knows of no scientific evidence demonstrating that whole-body scanning of individuals without symptoms provides more benefit than harm to people being screened.”

Similarly, while CGM can certainly be a helpful tool for some people with known blood sugar stability issues, whether the potential benefits outweigh the potential risks of applying the technology to someone without such a diagnosis is murky. In essence, this pros-vs.-cons question is what Dr. Levinovitz seemed to be getting at in his quote that kicked off this blog. It’s not that applying quantitative measures to our bodies and behaviors is always a negative; it’s that doing so is not always a positive either. Oftentimes, whether signing up for a CGM subscription service, buying a Fitbit, or downloading a calorie-tracking app, people go into such endeavors based solely on sales pitches and what they hope to get out of the experience while unaware of the risks that come along for the ride.

The Buffet: An Intuitive Eater’s Playground

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Out of all the situations that my patients find challenging, the buffet is the one they most commonly mention. No wonder that they do, as buffets are laden with many of the dynamics that can be tricky for budding intuitive eaters. Another way of looking at the matter is to think of buffets not as tests or proving grounds, but rather as playgrounds: a place to practice, have fun, and figure out which elements of intuitive eating might benefit from further work.

Consider the following factors and how you can use buffets to examine the role that they might be playing in your eating.

Quantity: As far as I can recall, every buffet I have gone to has been of the all-you-can-eat format without any external constraints to limit how much I ate. For people who are used to leaning on outside forces to put a cap on their quantity consumed – such as a restaurant’s serving size, the mound that mom puts on their plate, or a 100-calorie snack pack – buffets can leave them feeling lost and unsure when to stop. Some patients shy away from buffets for this reason, but I suggest instead running straight for them, as they present fantastic opportunities to practice recognizing and honoring our fullness cues. After all, without any external cues telling us when to stop, we have no choice but to look inward at our body’s cues to make the decision.

Cost: If you are a fan of the Phantom Gourmet, you have likely seen The Nordic Lodge featured several times over the years. Joanne and I went once several years ago to see what the fuss was about, and it certainly was an interesting experience. The adult admission price was lower than the current $125.00-per-person fee when we went, but it was certainly still expensive, and I found myself feeling anxious about making sure I got my money’s worth. Then I reminded myself that the entry fee was a sunk cost whether I stopped when I was comfortably full, made myself sick, or anywhere in between. Eating to the point of feeling physically gross was not going to somehow enhance the experience or make me feel differently about the money we spent. That is just me though, and I am not suggesting that there is a right or wrong answer here, as some people might indeed feel more positive about their overall experience if they leave a buffet feeling like they ate their money’s worth; but it is interesting to examine in real time how cost might be influencing your eating behavior.

Rarities: If you have attended The Langham Hotel’s chocolate buffet, you know that they do not allow doggy bags. Although our waiter did once discreetly slip me some extra napkins so I could wrap up a piece of pastry to take home, their official stance is you either eat the food there or you do not eat it at all. Feeling a pull to take advantage of a now-or-never, or at least a now-or-wait-a-long-time-for-another-opportunity, situation to eat something can be an example of beckoning. Even though some patients feel that eating in response to beckoning is a negative behavior, I disagree and feel it is a morally neutral action that is neither good nor bad. As I discussed in a previous blog, simply having an awareness of whether we are eating in response to humming or beckoning has its upsides, and there may be no better place to ask ourselves this question than at a buffet you rarely attend or may never go to again.

Scarcity: My college dining hall was an all-you-can-eat buffet format, but they nevertheless still ran out of the most popular foods sometimes. Although I cannot recall any specific examples, I know there were certain desserts that would run out quickly relative to the others. Whenever they were on the day’s menu, the race was on to get some before the other students finished it all. Looking back, I am certain there were days that I chose something not because I genuinely wanted it, but because I felt a competitive drive to get it before it was gone. Next time you are at a buffet and you spy an item that is running low, consider how your selection may or may not differ if the quantity were bountiful.

Dichotomies: One of my patients told me that when they were young and attended buffets with their parents, they sometimes tried to sneak extra quantities of “bad” food when their parents could not see them, such as taking some and eating it before they got back to the table. Some people feel compelled to balance out their intake of “bad” food by forcing themselves to take some “good” food too whether they really feel like having the latter or not. In reality, the dichotomies that people believe regarding food – whether they are good/bad, healthy/unhealthy, clean/unclean, etc. – have much less to do with science and more to do with the way we impose principles of spirituality on our eating. Buffets can be a great place to examine the role that such a dichotomy may be playing in your food choices.

Comparisons: Going back to our Nordic Lodge experience, I clearly remember looking around at other diners and their plates because I was curious to see how others were approaching the buffet. Some people take things a step farther by comparing their own eating to others. Such comparisons might be the basis for someone to feel virtuous or guilty about their own food choices. Beyond that, sometimes we might use the behavior of others as a determinant of the permission we give ourselves. For example, maybe we are considering going back for a third plate of food, but we do not give ourselves the green light until someone else in the party does it first, and if they never do, then we deny ourselves.

While buffets can feel triggering, they can be great playgrounds for practicing and developing our intuitive eating skills. Instead of shying away from the challenge, lean into it and have fun!

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.