“What should I do for exercise?”

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

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

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

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

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

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

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

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

Weight Stigma in Healthcare Harms Us All

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

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

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

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

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

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

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

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

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

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

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

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

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

Randomly Targeted

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

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

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

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

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

Outer Limits

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

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

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

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

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

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

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

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

 

Here Comes Mr. Greedy

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

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

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

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

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

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

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

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

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

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

The “T” Word

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

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

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

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

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

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

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

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

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

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

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

Questionable Measures

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Privilege and Cowardice: A Chronology

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“You should have hit her. She’s black.”

It is 1989, and I am a sixth grader struggling to adjust to life at Pollard Middle School. We are in music class. Instead of practicing their piano parts, two boys are sexually assaulting one of our classmates, laughing as they repeatedly grab her breasts and pinch her buttocks despite her best efforts to swat their hands away.

When the brown-skinned girl sees me looking at her, she recoils and asks me if I am going to touch her, too. No, I would never, that is not at all who I am. But she does not know that. The fear on her face suggests that despite her young age, she has already learned to see every boy as a potential assailant. I do nothing. Neither does the music teacher.

Two grades later, I am walking through the science department hallway after school has let out for the day. The corridor is mostly empty, just me, a younger girl, and the two aforementioned boys. One of the latter flinch tests the girl, acting like he is going to punch her before stopping his fist just before her face. She remains silent and does not react. As they walk away, one boy says to the other, “You should have hit her. She’s black.” Afraid they might come after me, I say nothing. I do nothing. I tell no one.

It is November 2015, I am reluctantly attending my high school reunion, and I spot him, the boy – now a graying man on the early fringes of middle age – who spoke those words in the science department hallway. As soon as I see him, I think of these two incidents and wonder how many women and minorities he has harassed, bullied, intimidated, and assaulted over the last few decades in part because I did nothing to stop him.

 

Kicked

It is early spring in 1995, and my time at Needham High School is nearing an end. The best player on our tennis team is a black student who buses between his inner city home and our suburban school as part of the METCO program.

The time he loses every morning and afternoon sitting on a bus is time that I and many of my suburban-dwelling peers can use to study, do homework, seek tutoring or extra help from teachers, participate in extracurricular activities, or even just relax or sleep, all of which help directly or indirectly with our academics and college applications. We have a leg up on him based on proximity alone.

Not only is my teammate a great player, but he is also a super nice young man who goes out of his way to help us with our own games, including teaching me how to hit a kick serve. Meanwhile, I am stuck in tennis purgatory, sandwiched between a varsity roster filled with players better than me and our coach’s policy against allowing seniors on junior varsity. Coach explains to me that after three seasons together, he feels too bad to cut me, but that I should cut myself because I am not going to play. I refuse to do so and remain on the team solely as a practice hitting partner.

My personal and familial responsibilities enable me to spend every afternoon out on the courts, but my teammate has other obligations. He misses some practices, and coach tells him that if it happens again, he is gone. Then he misses another day because he has to give his brother a ride. Coach kicks him off the team, citing a lack of commitment. He cannot be in two places at once. What is he supposed to do? Yet none of his now ex-teammates come to his defense, at least, not to my knowledge.

As a result of his expulsion from the team, I get promoted to the varsity lineup and have an unexpectedly great season – thanks in part to my new kick serve – that springboards me to playing for my college.

It is my senior year at Tufts University, and not only do I get to tell potential employers that I am a collegiate athlete, thus implying that I possess a disciplined work ethic and an ability to function as part of a team, but I can add that I have been named a co-captain, suggesting that I have leadership qualities and the respect of my peers. Can my ex-teammate from high school list either of these accolades on his resume?

 

Being Followed

It is the summer of 1995, and I am a recent high school graduate working my first “real” job at Thunder Sporting Goods in Wellesley, the town in which gun-drawn police forced black Celtics player Dee Brown from his car and ordered him to lie on the ground in a case of mistaken identity five years earlier. Brown, who was originally from Florida, went on to say, “When you think of towns up North and you think of racism, you think of Boston.”

My duties primarily entail stringing tennis racquets and selling running shoes, but on this particular day, my manager gives me a different task. A neighboring retail store down the block called him to report that a black person had just been in their store and was apparently headed in our direction. My manager tells me to follow them around the store to make sure they do not steal anything.

His racist directive shocks me, yet I am intimidated by my boss, my first one ever, so I plan to keep myself busy with tasks in the same general vicinity as the shopper, but no way am I going to blatantly follow them around the store. Not a great plan, but in my 18-year-old brain, it feels like a compromise of sorts. As it turns out, the person takes their business elsewhere and never enters our store.

 

The “Bloody Shirt” Incident

It is 1996, I am a college freshman, and I agree to help a friend paint the set for her drama production. Afraid of getting paint on my nice sneakers, I wear my running shoes. It is late at night by the time I leave the scene shop, and since I have my running shoes on anyway, I decide to save some time and jog back to my dorm.

A policeman working a construction detail yells at me to stop. He sees red on my shirt and thinks I was involved in the fight he heard about over his radio. It is just paint, I tell him. Without getting close enough to me to verify my claim, he takes me at my word, and I continue running into the night. Now I have a somewhat amusing story to tell friends about the time a policeman briefly mistook me for a violent perpetrator. I am white.

 

Daewoo(d)

It is June 1999, and I am a recent college graduate. My girlfriend and I land in Las Vegas with plans to rent a car and drive to Phoenix and then San Diego for a short vacation before I enter the working world next month. The rental agency gives us the choice between two vehicles: a car to which they cannot find the key or a sketchy Daewoo without a license plate.

Somewhere in the Arizona desert, we get pulled over for speeding and driving a car without a license plate. Both policemen are friendly, and as one of them does whatever it is that cops do in their cruisers during traffic stops, the other remains by our Daewoo and jokes that maybe the last D on the car had fallen off, as he has never heard of the make before, but he knows of an electronics company by the name of Daewood.

The only emotions I am experiencing are shame and embarrassment for having been pulled over. Fear for our safety or even a theoretical notion that a routine traffic stop could turn violent never cross my mind. Despite being egregiously guilty of both offenses, we are sent on our way in our plateless car with neither a ticket nor a written warning. My girlfriend is also white.

 

Playing Fields

It is 2004, and I go back to school for nutrition at the University of Massachusetts Amherst. Driven by a fear of failure, I do everything I can to be academically perfect. In general chemistry, I answer literally every practice question in the textbook, even ones not assigned as homework. In organic chemistry, I attend the TA’s office hours, the professor’s office hours, and the on-campus tutoring department’s study groups every single week. My anxiety drives me to attend chemistry classes that I am not even enrolled in, just so I can hear the material presented over and over again.

My work ethic is as solid as osmium, but so are those of many of my classmates. Unlike some of them, I have finances working in my favor. Whereas some classmates have to load up on courses in order to finish the program as quickly as possible rather than rack up tuition costs for additional semesters, I go at a leisurely pace and never take more than four courses in a given semester. Instead of toiling endlessly at a job just to get by, my part-time gigs as a personal trainer and a dietitian’s assistant rarely sum to more than 15 hours in a given week. While our efforts are more or less equal, theirs are spread thinly over several demands whereas mine are more focused. I can afford – both literally and figuratively – to do this because I have personal savings and financial support from my parents.

Upon graduation, I have a 4.0 GPA, a handful of merit scholarships – including one for my achievements in organic chemistry – and an offer to work for free at one of the most prestigious dietetic internships in the country. Some of my classmates are not matched to an internship and are forced to pivot their career paths away from nutrition.

Because of my financial situation, I can accept my placement in the unpaid internship, the name recognition of which helps me to land my first job as a newbie registered dietitian.

 

The Iceberg’s Tip

It is June 2006, and I am in the early stages of a Seattle-to-Boston charity bicycle ride with a small group of other cyclists from around the country.

Riding into Clark Fork, a small and isolated town in the Idaho panhandle, I am shocked to see Confederate flags and pro-KKK signs openly displayed in front of a good portion of the homes.

That evening, the only black rider on our trip and I head to the local laundromat. As we walk, I tell him how surprised and horrified I am to see that such blatant racism still exists in our country, as I thought that we as a nation were past all that.

He explains to me that because I am white, I have the privilege of moving about the world largely ignorant of racism until it is glaring in my face like it is here in Clark Fork.

He is right, I realize. More than any other lesson that I learn about myself or America during our 4,024 miles across the continent, his is the one that sticks with me.

 

Community

It is the winter of 2007-2008, and my internship rotation has me working on a roving healthcare van that travels to parts of Boston that I have previously steered clear of because I associate them with violence. We park in the heart of Mattapan to conduct various screenings, such as blood sugar and blood pressure checks, distribute free condoms, and answer as best we can whatever health-related questions and concerns are voiced by our visitors, virtually all of whom are black.

On one of our lunch breaks, my preceptor takes me to Ali’s Roti Restaurant because she wants me to experience a cuisine I do not encounter in the suburbs. We browse a neighborhood grocery store so she can show me the food supply available to the neighborhood’s residents. She points out organ meats and animal parts that I never would have thought of consuming before, but they are commonplace in other cultures. Note how prevalent and cheap the sugary drinks are in comparison to other beverages, she tells me. People can only buy what they have available to them and what they can afford, she explains.

We visit a food pantry, and I talk with people eagerly lined up to receive loaves of bread so old that there is no way I would eat them myself unless I was, well, starving. While I know of the existence of food pantries and understand them in an academic sense, this is my first time really experiencing one and interacting with people who rely on them to feed themselves and their families. I go home and make myself dinner in my fully stocked kitchen.

 

Readings

It is the early summer of 2008, and I have just completed my dietetic internship. A seasoned dietitian asks me to help her at a community healthcare event. People will be coming to us for information and screenings, very similar to those that I performed while on the roving healthcare van.

“If you can’t read someone’s blood pressure,” she says, “just tell them it is 120/80.”

The ethical choice and the one that prioritizes patient care is obviously to disregard her directive, but I feel intimidated by her, and I want to stay on her good side in hopes that she might help me with my job search. Fortunately, I am pretty skilled at taking blood pressure, so I never have to cross this bridge.

For our visitors, the vast majority of whom are black, this community event is essentially their annual physical. I imagine someone coming in for a blood pressure check, giving them a fabricated 120/80 result, and sending them on their way thinking they have normal blood pressure when really they have hypertension that subsequently goes untreated and leads to a stroke.

It is June 2020. I read that blacks are 50% more likely to have a stroke in comparison to whites and I wonder: Is the biology of skin pigment really the causal factor here, or is it everything else that comes bundled with being a minority in a country fraught with social disparities and systemic racism?

 

Welcome to Food Insecurity

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The pasta aisle at the Wellesley Whole Foods on March 13, 2020.

Some of the earliest dietary guidelines emphasized high-calorie foods, like butter and margarine, because so many young men were failing their military physicals due to malnutrition. Unlike some of our ancestors, who struggled through or perished in famines or economic depressions, my generation in this country has been lucky in that we could take our access to food for granted.

Of course, numerous exceptions exist. Needham’s food pantry and the SNAP stickers on supermarket refrigerators are evidence that some of our very own neighbors struggle to get enough to eat. When I visited grocery stores on isolated Native American reservations in middle-of-nowhere regions of Montana and North Dakota in 2006, I was floored by how limited the selections were. Poverty and food deserts are not the sole factors that can limit access to food, as some of my pediatric patients growing up in restrictive households could tell us. Dieters know that food scarcity can be self-imposed.

For the rest of us, the panic surrounding COVID-19, the associated hoarding of supplies, and the resulting empty shelves have inducted us into a sensation that so much of the human race has known, but we were too privileged to experience it firsthand.

Welcome to food insecurity.

Whether or not our food supply chain is actually at risk for significant disruption, the mere perception of a threat is enough to trigger feelings of food insecurity. We see the pasta shelves and potato bins empty, the milk section vacant, frozen produce nowhere to be found, and other typical supermarket staples gone, and we feel a visceral reaction that we had better get what we can while we can. Hence, we hear stories of people making purchases that in other circumstances would make little sense. For example, one of our patients was at Costco and ended up buying a gallon of mayonnaise, a condiment she does not even typically use, just because she could get her hands on it in the midst of the frenzy.

We can understand why. Dieters know that restriction, or the mere threat of it, triggers overconsumption. Thematically, little difference exists between someone loading up a shopping cart with whatever items they can and a person who overeats on the weekend while telling themselves, “Diet starts Monday.”

When it comes time to eat, the veil of food insecurity might compel us to finish all that we have served ourselves, lest we “waste” food by leaving it uneaten. My suggestions are to understand the source of these feelings and to validate them, but also to realize you still have a choice and remove moralization from whatever decision you make.

Keep in mind that we have in our lineage ancestors who survived extraordinary circumstances and may have attempted – for better or for worse – to instill their survival skills in us. For example, my grandparents, who grew up during the Great Depression, used to pressure me to clean my plate. As another example, one of my patient’s grandmothers is a Holocaust survivor and made it through her horrific ordeal by eating whatever she could whenever she could because her next feeding opportunity was never guaranteed; like my grandparents, she pressures my patient to eat more than he can comfortably consume, too.

In terms of what to do about potential overconsumption, there is no blanket answer that is right for everyone. Instead, I encourage people to be aware of the dynamics involved in their eating decisions, including any pressures and threats related to food insecurity that might be at play.

Consider the role that stress might have in your eating decisions and know that – contrary to what diet culture tells us – emotional eating is an understandable and relatively benign response to these troubling times. We all have to deal with our stress somehow, and each of us has a different toolbox of coping strategies. Before you feel badly about eating extra in an effort to soothe yourself, remember there are people in your neighborhood reacting to their stress in much more destructive fashions, such as shooting heroin or beating up their spouse. Eventually, we can expand our repertoire of coping options so that eating is just one of many choices we can make to de-stress.

Ultimate decisions matter less than having taken the time to thoughtfully arrive at them. Weigh the pros and cons of whatever options you face while understanding that none of them is likely perfect, choose the one that in balance feels the most right to you, and know that you are neither guilty nor virtuous for whatever choice you make.

Keep in mind that these times will not last forever. Quarantines and social distancing directives will end, restaurant dining rooms will reopen, and grocery store shelves will be fully stocked once again. When they do, be on the lookout for residual behaviors that may date back to your days of food insecurity, as we know from our ancestors that such behaviors can stick around long after the threat is gone.

Immunity Boosters?

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If you are like me, you have noticed the seemingly greater-than-normal prevalence of illnesses circulating this winter, and perhaps you have suffered some of them yourself, too. No wonder people are looking for foods, nutrients, and supplements that can help them get or stay well.

So which ones help? Well, admittedly, this piece has taken a very different shape than I expected it to when I first started writing. It would be straightforward, I figured; just research the most popular immunity boosters and summarize which ones work and which ones do not. However, my expectation stemmed from having fallen into the trap of oversimplification that so often affects how our culture sees foods.

In reality, there is nuance, as I quickly remembered, and the moving parts are numerous. To suggest blanket statements about effectiveness is a variation of the oversimplified good/bad food dichotomies that are so prevalent in our culture, yet they are nonsensical without specific context.

Consider some of the variables:

Effectiveness

What does “boosting” our immune system really mean? Our immune systems are comprised of various structures and mechanisms, so when one talks of “boosting” the system, what specifically is supposedly being increased and by how much? Furthermore, do we really want to turn the dial up on our immune systems, which theoretically could result in an autoimmune disease?

When people say they want to boost their immune systems, really what they are expressing is a desire to get over an illness faster, or experience a sickness milder than what they otherwise would have, or avoid getting sick in the first place. However, these three goals are different from one another, as are the bacterial and viral invaders that exist in a wide array, so any potential immune system booster could differ in effectiveness in achieving each of the three outcomes for each of the numerous potential illnesses. Therefore, a study that demonstrates biological responses to garlic does not tell us much about bottom-line effectiveness, but rather paves the way for further study.

Dosage

The administration of a potential immune system booster has within it its own set of variables, including how much, how frequently, and which delivery method. Further complicating matters is the potential for dosage variation from person to person.

A study on vitamin C found that plasma levels of the vitamin measuring 100-200 mg/day were required for effective prevention of potential infections, but how many oranges must one consume to reach such serum levels? One, five, maybe more?

Population

Effectiveness and dosage may depend on age, weight, physical activity, hydration level, health conditions, or any of the other factors that vary from person to person. Zinc, for example, has been shown to significantly reduce the duration of cold symptoms in adults, but not children.

Risks

Looking to a food, nutrient, or supplement to help fight off an illness has potential downsides. Zinc can cause nausea when consumed orally, and it can trigger a copper deficiency if taken excessively because the two minerals compete for the same absorption sites. Meanwhile, more subjects taking echinacea dropped out of double-blind prevention trials than those taking placebos due to adverse effects. Because supplements are unregulated, we have no way of knowing if the bottle of echinacea that we purchase even contains the herb as advertised.

Somewhere out there lies a truth, but discovering it is a more difficult proposition than some realize. With so many variables at play, designing and conducting informative studies is a monumental challenge. We need large bodies of well-constructed research and replication of results from one study to the next with similar parameters, and all of that takes time, money, and effort.

The current research may yield little more than a shrug of the shoulders, but meanwhile, the population at large still yearns for an answer. “It’s terrifying to live in a place where the causes of diseases like Alzheimer’s, autism, or ADHD, or the causes of weight gain, are mysterious,” says Professor Levinovitz, a religion professor who has taken to writing about nutrition in recent years because of the intersectionality between spirituality and food. “So what we do is come up with certain causes for the things that we fear. If we’re trying to avoid things that we fear, why would we invent a world full of toxins that don’t really exist? Again, it’s about control. After all, if there are things that we’re scared of, then at least we know what to avoid. If there is a sacred diet, and if there are foods that are really taboo, yeah, it’s scary, but it’s also empowering, because we can readily identify culinary good and evil, and then we have a path that we can follow that’s salvific.”

Dr. Levinovitz’s words remain true regarding ailments ranging from the coronavirus to the common cold. Nobody wants to hear that the answers are complex, nuanced, or blatantly unknown when they are anxious and looking for control over their fate.

In order to fill the void, in step those looking to gain notoriety or money. In the eyes of desperate people, the accuracy of an answer seems far less important than being able to provide one. This dynamic likely explains why so much of the misleading and biased information online regarding immunity boosting stems from commercial websites.

So which foods, nutrients, and supplements actually do help us to have shorter and milder illnesses or help us to avoid getting sick altogether? Truthfully, I have no idea. Now excuse me while I go take my elderberry syrup.