“I have to get rid of these leftovers or I will eat them all.” Sound familiar? The “them” in question could be leftovers from any holiday celebration that includes food, such as Halloween candy, Thanksgiving pie, Christmas cookies, New Year’s Eve hors d’oeuvres, Easter jelly beans, Memorial Day barbecue, or birthday cake and ice cream.
The aforementioned strategy for dealing with such leftovers sounds logical on the surface and might even seem to work for a little while. If the food is not there, you cannot eat it, right? As the never-ending cycle of holidays continues though, the strategy of avoidance reveals its downsides: stress, anxiety, deprivation, reinforcement of an oversimplified and misleading good/bad food dichotomy, and increased risk for episodes of overeating or outright bingeing.
An alternative does exist, one that takes less mental and emotional energy, allows people the freedom to enjoy holiday favorites without going overboard, and makes peace with food. This alternative is stocking, which is a well-known technique among practitioners who help people with emotional eating, compulsive eating, binge eating disorder, and supposed food addictions.
Stocking is the antithesis of quickly ridding the house of holiday leftovers, and it may initially seem counterintuitive. A full explanation of the technique requires more time and space than would be appropriate for this newsletter, but here are the highlights for your consideration.
Uncouple morality from food and eating behaviors
In order to feel more comfortable with stocking, people need to rid themselves of the good/bad food dichotomy and be able to temporarily put the hard science of nutrition on the back burner. Not all foods are the same nutritionally; it would be ridiculous to proclaim that an apple has the same nutritional value as a Twinkie, and I am not arguing otherwise. What I am suggesting, however, is to strip the moralization away from food. An apple is just an apple; you are not good or virtuous if you select it for your snack. A Twinkie is just a Twinkie; you are not bad, guilty, or weak-willed if you choose it instead. Sometimes your body’s cues will lead right to the apple, other times to the Twinkie, and either outcome is okay.
Establish an abundance of food at home
Identifying what food will feel best in your body means little if you do not have a reasonable shot of providing said food for yourself. Therefore, one of the tenets of stocking is to keep a wide variety at home, including foods that are seen as taboo and can trigger overeating or bingeing.
When our body is asking for a food we do not have on hand, we tend to overeat on the foods that are in the house. This can certainly occur with both adults and children, but we especially see this with teenagers who live in food-restricted households. Well-meaning parents might keep foods high in salt, sugar, or fat out of the house because they think that doing so creates a healthy food environment, but oftentimes it backfires. For example, the teenagers overeat on low-sodium potato chips that never really hit the spot while a small amount of regular chips would have done the trick, or they overeat on Newman’s Own fig cookies when really they just want a couple of Oreos.
Select foods based on intuitive-eating cues
One of the logistical differences between those who practice intuitive eating and those who do not is how food selection begins. Standing in front of the open refrigerator or scouring the pantry and cabinets and selecting whichever foods call to you is an external process that differs greatly from asking internal questions about what temperature, texture, flavor, color, etc., food will feel best in your body at that moment and seeing where it takes you.
These cannot be treated as leading questions. In other words, if you have stocked up on, let’s say, Ben & Jerry’s Cherry Garcia, and you are trying to convince yourself that your body does or does not actually want the ice cream, then stocking will not work. Keep an open mind, ask these questions neutrally, and see where your body’s cues take you.
Maintain the inventory of foods at home, especially of triggering foods
Maintaining the abundance of food in the household is an important element of stocking. If the supply dwindles, you might feel like you need to hurry up and eat a particular food while it is still around. Should you ever run out and then buy it again, the food regains its luster. If you are stocking Doritos, for example, maintain a supply of, say, ten large bags at home. As soon as you finish two bags and are down to eight, go out and buy two more.
Be patient and use a neutral voice
Initially, you may find yourself eating certain foods when your body does not actually want them, but as you keep up the practice, eventually your trigger foods will blend in with all of the other foods in your pantry and no longer sparkle the way they do when they are brand new to the house. Until then, abstain from judging yourself harshly for eating episodes that do not go as you would have liked. Remind yourself that you are still in the early stages of the process and you are learning. With a neutral voice, examine what happened so you can respond differently when similar circumstances arise in the future.
Enjoy your new-found peace with food
Imagine how different your experience with leftover Thanksgiving pie would be if you routinely kept slices of pie in your freezer for whenever your body wanted them. Contrast the fretting you feel about the remaining Halloween candy to the relaxed liberation of always having a few bags of peanut butter cups in the pantry year-round.
For the stocking technique to be successfully implemented, foundational work to dispel nutrition myths, break up the good/bad food dichotomy, and uncouple moralization from food choices is necessary beforehand. Because this process takes time, it is probably too late for the stocking technique to be much help for you this Thanksgiving unless you have already been working on these prerequisites.
The cycle of holidays will continue though, so if you get started now, you might find you have a much more relaxing and enjoyable experience with this February’s Valentine’s Day chocolates than you would have if you continued down your current path.
[Preamble: After the conference I am about to discuss came to an end, I sought and received permission from the organizers to use their slides in my blog. The only stipulation was that I had to credit the authors, most of whom I disagree with strongly, and this requirement gave me pause. While I may not see eye to eye with these doctors, I respect them enough as colleagues not to publicly embarrass them by name. The internet is an unnecessarily harsh place sometimes. Everything I am about to say is in the spirit of constructive criticism, not trolling, and I can make my points without calling anybody out. When it comes down to it, all of us are on the same team. Or at least we should be.]
During an early break between presentations, I took a walk through the exhibit hall to see which vendors were in attendance and approached one weight-loss company that advertises, “The [company name omitted] was developed by doctors and is clinically proven to be safe and effective for weight loss.” Pretty much any kind of restriction will lead to short-term weight loss, so I always find it interesting when companies act like their program is unique in this way. According to the company representative working the table, he told me the people who go through their program consume between 800 and 1,300 calories per day.
Let’s put this calorie intake in perspective. According to the Food and Agriculture Organization of the United Nations, Somalians consumed an average of just under 1,700 calories per day per person between 1999 and 2001, which made the citizens of this east African nation some of the most undernourished in the world during that time. The situation in Somalia continues to be so dire that in fiscal year 2015, the United Nations World Food Program, with help from countries including the United States, delivered 40,680 metric tons of emergency food assistance to the people of Somalia.
Think about that. American dieters who follow this “safe” weight-loss program consume a level of nutrition so inadequate that if they were eating this little and living in a different region of the world, the United Nations would be sending cargo ships full of food to help them. When is Bob Geldof going to organize a star-studded benefit concert for dieters?
The diet program’s marketing material advertises, “And once you’ve reached your goals, [company name omitted] support continues with our Healthy Living Program, where you’ll learn how to transition and maintain your new, healthier weight for the long term.” Where is the evidence to support this claim? It only took the gentlest of pushes for the rep to concede he had none.
We do, however, have plenty of evidence to the contrary, including, but not limited to, the starvation study Ancel Keys conducted in 1944. After consuming approximately 1,570 calories per day (which, just to hammer home the point, is more than people on this diet program are afforded) for an extended period of time, the subjects, according to Judith Matz and Ellen Frankel, “. . . engaged in binge eating for weeks yet continued to feel ravenous. They overate frequently, sometimes to the point of becoming ill, yet they continued to feel intense hunger. The men quickly regained the lost weight as fat. Most of the subjects lost the muscle tone they enjoyed before the experiment began, and some of the men added more pounds than their pre-diet weight. Only after weight was restored did the men’s energy and emotional stability return.”
Data presented throughout the conference reinforced the long-term failure of diets as well. Among the slides are nine graphs showing data from various weight-loss attempts and they all depict the same pattern: sharp initial weight loss followed by slow and steady weight regain. A couple of the presenters discussed the hormonal and neurological survival mechanisms that kick in to promote weight regain after the body has experienced a period of restriction.
The discussion of these data and physiological reactions represented what I consider a noteworthy shift since last year’s conference. In 2014, very similar graphs were shown as well, but back then the weight-loss attempts were presented as successful because the end points were lower than baseline, even if the studies were short term and the trajectory of weight regain was still going up at the time of the study’s conclusion. This time, presenters were more forthcoming about the dismal results of weight-loss interventions.
Of course, that did not prevent them from hosting a vendor who sells weight-loss programs, nor did it keep some presenters from going into detail about lifestyle interventions that would supposedly lead to weight loss. The height of irony was at the end of a long day of discussing how diets do not work, the last presenter stepped to the podium and offered a how-to tutorial on dieting: measuring portions, daily weigh-ins, using apps that track calories, etc.
Not only did she recommend Weight Watchers, which in itself was as funny as it was horrifying, but she also cheerfully offered a list of “Plans that may be effective short-term (≤2 years) for weight loss,” including low-carbohydrate, low-fat calorie restricted, Mediterranean, vegan, vegetarian, and Dietary Approaches to Stop Hypertension (DASH), without any mention of what happens beyond two years. Did she think we would not notice such a glaring omission?
She also included a slide depicting a large polar bear trying to fit into a tiny igloo with the caption, “When it comes to management of obesity, one size does not fit all. Keep trying . . . and eventually you will find the perfect fit.” On what is she basing this claim? We saw no evidence presented whatsoever that any current methods of weight loss work in the long term except for a small fraction of individuals.
Presenting these behaviors and diets as the key to long-term weight loss makes no sense, not when so many other people perform the same actions without achieving similar success, as evidenced by, among other indicators, the multitude of graphs and data they just showed us. The lottery crowns new millionaires every single day, but that does not mean your financial advisor is giving you sound, ethical, evidence-based advice if he suggests you take your life savings and invest in Powerball tickets.
A friend recently sent me a New York Times article entitled “The Decline of ‘Big Soda'” and asked me my thoughts. The article begins with this opening line:
“Five years ago, Michael A. Nutter proposed a tax on soda in Philadelphia, and the industry rose up to beat it back.”
Okay, let’s stop right here. Once upon a time, I felt ambivalent about the idea of a soda tax. Now, however, my stance is clear: I am firmly against a soda tax.
Our country’s health woes are complex, only partially understood, and not entirely in our hands to fix, yet for reasons that baffle me, we continue to place too much confidence in our oversimplified supposed solutions. Perhaps people are scared, yearn for a sense of control, and find it more comfortable to point fingers at scapegoats than to face the truth. Human history is riddled with atrocities stemming from scapegoating, and in the world of nutrition, the blame game is harmful as well.
Taxing one food, nutrient, or ingredient separate from the others reinforces a “good food, bad food” dichotomy. Eating only “good foods” is largely unsustainable for most people, and although doing so might sound good in theory, the reality is that such rigid eating often comes at the expense of health’s other facets. When we ultimately consume foods we view as “bad,” feelings of guilt and shame quickly follow. A popular misconception is that feeling bad about ourselves will inspire change, but actually quite the opposite is more the norm. The worse we feel about ourselves, the less inclined we are to treat ourselves well. We eat a “bad” food, feel guilty about it, and proceed to take worse care of ourselves.
Better to recognize that the “good food, bad food” dichotomy is a harmful system, remove moralization from eating, and instead teach people the importance of individuality and moderation. After all, one person’s “bad food” is someone else’s “good food” and vice versa, so what do those labels really mean anyway? Cantaloupe is high in potassium, which makes it very helpful for my patients with hypertension but quite problematic for my patients with kidney disease who are on potassium restrictions. So, is cantaloupe a “good food” or a “bad food”?
If the basis of the soda tax is the beverage’s sugar content, then why are sodas singled out while sports drinks, iced teas, chocolate milks, smoothies, lemonades, fruit drinks, milk alternatives, yogurt drinks, and other sugary beverages skate by without a special tax? Orange juice has almost as much sugar (31 grams per 12 ounces) as Coca Cola Classic (39 grams per 12 ounces), so why are we not stigmatizing OJ?
One might argue that orange juice has upsides despite the sugar content, a point with which I completely agree, but the same is true for soda as well. Every single food you see in the grocery store, including soda, has its upsides; otherwise, nobody would buy it, the store would cease stocking it, and it would not reside on the shelves for you to see.
Sugar is dense in calories, and calories are a measure of energy, so for our neighbors whose financial hardships make getting enough food a daily battle, soda is a cheap source of energy. Increasing taxes on low-cost foods places additional pressure on the already financially strapped people who are most likely to make such foods a staple of their diets out of necessity. When people talk about racism, classism, and privilege in healthcare, the soda tax is an example of what they mean.
For those with medical conditions that make consuming enough energy a challenge, such as cancer, HIV, and anorexia nervosa, the caloric density of sugar-sweetened beverages makes these drinks, including soda, helpful options. Let’s not create additional issues for people who are already sick by specially taxing and stigmatizing the beverages that are part of their care.
For other people, soda is a play food, something that they simply enjoy even if it is not the best option for their health. Whether they partake only occasionally or frequently is irrelevant. All of us engage in a whole slew of activities that do not prioritize our health. We know how detrimental inadequate sleep can be, so why not institute a special tax on people who do not get enough? Why don’t we impose a tax penalty on people who live in cities with poor air quality? Let’s place an additional tax on people who are not physically active, or at least not as active as some other people think they should be. High heels can lead to orthopedic problems, so let’s tax stilettos more than other footwear while we’re at it.
Penalizing other people for their behaviors and how they choose to balance their health with life’s other elements suddenly loses its coolness factor once we realize that opening the door to this kind of judgment means we ourselves are subject to similar stigmatization and punishment, too. In other words, the finger that currently points at them might someday swing right around and point directly at you.
As my freshman year of high school neared its conclusion, my math teacher, Mr. Evers, stood at the chalkboard and drew a large square, which he said represented the entire field of mathematics. He asked us how much of that square we thought we would learn by the time we graduated from high school. After fielding a few guesses, he gave us his answer by filling in a very small corner.
That blew my mind. At the time, I was a solid math student and I wondered how there could possibly be so much more to the discipline beyond what we already had under our belts. Once I got to Tufts and decided to major in the subject, I was introduced to sections of that square I had never even heard of before: complex analysis, abstract algebra, discrete mathematics, differential equations, linear algebra, number theory, numerical analysis, etc.
By the time I finished my degree, I had stretched my mathematical abilities to their fullest extent. Subsequently, more talented classmates of mine who continued on to graduate school in the field explored areas of the square that we never touched as undergrads.
Even the boundaries of that square are expanding as the field grows. A few years ago, a publishing company contacted me and asked if they could feature me in one of their textbooks, so I reached out to a couple of my favorite math professors to let them know. In one of their replies, he included mention that his current research is focusing on how the topography of a rotating sphere, such as a planet, can be mapped based on data collected from its poles. Well, we certainly never covered that in high school.
When Mr. Evers filled in the corner of his square, I learned an important life lesson that sticks with me today and reverberates through my work as a dietitian: A little bit of knowledge can be worse than no knowledge at all if we do not understand the context and erroneously believe ourselves to be experts.
Flipping through the study guide for one of my personal training certifications, I count 15 pages on nutrition. Unfortunately, some trainers learn the material in this one chapter and incorrectly believe themselves to be nutrition experts. When I hear trainers at the gym talking with their clients about food, way more often than not the information they are offering is grossly oversimplified at best and blatantly false and/or dangerous at worst.
Reading a handful of pages on nutrition does not make one a nutrition expert, just like reading the chapter in the same study guide about interpreting electrocardiogram results does not put me on the same level as a cardiologist. Too often, the greater context goes ignored or forgotten: Guys, that one nutrition chapter is nothing more than the tiny filled-in corner of my math teacher’s square.
This is not about picking on personal trainers; all practitioners, regardless of discipline, have bounds to our professions and we are all responsible for recognizing the limitations of our expertise. One of my patients, reluctant to work with a psychotherapist, asked me, “Can’t you just handle the therapy part?” Well, no, I cannot, although I was flattered that he felt comfortable enough with me that he would ask. Even Joanne, who has a degree in psychology, recognizes and respects the vast chasm between being able to identify the need for therapy and having the expertise to provide it.
The more we continue our education, the more we realize just how much learning still remains, not just on an individual level, but on that of our field and society as a whole, too. When it comes to nutrition, realize that graduate students, professors, and other researchers are all working diligently at universities, hospitals, and research centers across the globe in search of answers to outstanding and complex questions regarding food.
Part of actually being an expert means recognizing the grays and nuances, the dearth of crisp absolutes, and that sometimes the best answer to a patient’s question is, “I don’t know, but let’s see what we can do to find out.”
“You’re an RD, right?” That’s what one of my patients asked me last year shortly before he got up from the table and walked out of my office, never to return. It was more of a rhetorical question, really, his polite way of telling me I don’t know how to do my job.
He and I were only in each other’s lives briefly, as that was not only his last visit, it was also his first. His new patient paperwork stated that he wanted to lose weight in order to complete a marathon. Upon reading that, I contacted him in advance of his visit and offered a heads-up that I would help him to run his best, and as a consequence of doing so, he might also lose weight; but I would not be helping him to lose weight in hopes that it would improve his running because – contrary to popular belief – that is not how things actually work.
Although I suspected he would respond by cancelling the appointment, to his credit he had an open enough mind to meet with me and discuss our different points of view. Elite marathon runners are all very skinny, he told me, so it only seemed logical to him that if he could alter his body to look more like theirs, then he would in turn become a better runner.
Way back in my sophomore year of high school, I held the same belief. When I looked at those teammates on my track team who were faster than me, I noticed that for the most part they were leaner than me. Consequently, I attempted to change my body by restricting my fat intake (Back in those days, people were scared of fats the same way people nowadays fear “carbs.”) in hopes that I would also run better.
In fact, I ran worse. My mom took me to a dietitian who educated me, dispelled some of the nutrition myths that I held, and convinced me to increase my fat intake. My times in all events dropped, and I was the fastest I had ever been in my young running career without my physique ever changing all that much.
Having a leaner, smaller, or lighter body can certainly have athletic upsides sometimes, just as having a heavier or larger body can sometimes be advantageous, and I am not arguing otherwise. However, a significant difference exists between an athlete who naturally has a given size or shape versus someone who tries to force his or her body into that mold. That is where so many people, like my 15-year-old self and the patient I mentioned earlier, get tripped up.
Anecdotally, we see many examples of athletes who perform worse after intentionally losing weight. Last month, I wrote about how CC Sabathia has struggled since cutting his carbohydrates in an effort to lose weight. He and his slender frame are in the midst of experiencing the two worst seasons of his career, both of which have come since he lost weight.
Sabathia gave an interview earlier this year in which he talked about the fatigue he now experiences. Carbohydrates are our main source of energy. Now that he follows a low-carbohydrate diet, no wonder he currently tires early in games now. Only twice in my life have I failed to complete bicycle routes that I set out to ride. The first was when I fell off my bike in Montana and fractured my back. The other was when I was briefly experimenting with a low-carbohydrate diet and did not have the fuel necessary to make it home.
This summer, I had a couple of rowers come to me hoping to lose weight so they could compete in lightweight crew. Each of them believed that if he could shed enough weight to just make the 160-pound cutoff, he would dominate. However, they were not taking into account that the processes necessary to alter their bodies (over-exercise and/or dietary restriction) were likely to leave them unable to put forth optimal performances. A well-nourished and properly-trained 159-pound athlete is probably going to row much better than his or her 159-pound teammate who maintains that weight by existing in a state of depletion.
At the same time, let us acknowledge that not every athlete is already at the weight at which they can perform his or her best. Some athletes, just like the rest of the population, are subject to behaviors, such as emotional overeating, that might be impacting weight. However, putting the horse before the cart means directly addressing issues that might be hindering performance while allowing weight change to naturally occur or not occur as a consequence. To try losing weight in hopes of becoming a better athlete though is to have the process backwards.
She Said
Some of the individuals who come to see me for nutrition counseling are student athletes who are struggling with an eating disorder (ED). These cases are particularly challenging, as one of the cruxes of being an athlete (at least at a competitive high school or college level) is making sure one is in top physical condition to succeed in one’s sport. While this desire to be in the best athletic condition might be approached in a healthy and manageable way by some individuals, for those who are predisposed to EDs, it can sometimes start, trigger, and/or worsen the individual’s ED.
In the sports where weight control is believed to be paramount to success (e.g., gymnastics, ballet, track and field, etc.), this focus and, in some cases, obsession with being “lean,” “fit,” or “cut,” can result in the athlete eating in a restrictive manner (e.g., cutting out carbohydrates, only eating vegetables and protein) and exercising excessively. Initially, these individuals seem to be doing the right thing, taking care of themselves and making the sacrifices needed to become the best at their sport. The problem arises when the obsession with weight, food, and exercise takes over the athlete’s life. Examples of this include avoiding social situations that involve eating in order to train harder at the gym, exercising even while injured or sick, and panicking when being faced with foods that are not on the “clean eating” food list.
While these scenarios are red flags in and of themselves, the physical ramifications of these behaviors are serious as well. One of the most common outcomes that results from overtraining and undereating in female athletes is the Female Athlete Triad. This syndrome is characterized by three conditions: energy deficiency with or without a diagnosed ED, menstrual disturbances or absence of period completely (amenorrhea), and loss of bone density resulting in osteopenia or osteoporosis. In a nutshell, when an athlete is not eating enough to fuel her training, this can lead to dangerous health problems.
Some health professionals believe that individuals who are dealing with the above problems can continue to participate in their sports as long as they are getting nutrition education from a registered dietitian and having regular check-ups with their primary care physician to make sure they are medically stable enough to compete. While I agree that for some individuals it is just a matter of education and monitoring, for those with EDs, allowing them to continue with their sport could greatly hinder the recovery process. An ED is a multifaceted problem that needs a full treatment team including a therapist, dietitian, and doctor who is knowledgeable about EDs. The focus should be on helping the athlete become physically healthy while dealing with the underlying psychological issues that are part of the ED.
When I am working with a student athlete who is exhibiting disordered eating and/or excessive exercise, I always defer to the physician on the treatment team to make the call about whether the patient is medically safe enough to participate in his or her sport. The work I do with the patient centers on helping them understand what their body’s needs are fuel-wise. This might include educating the patient about carbohydrates and why they are a necessary macronutrient (for athletes and non-athletes) and how to eat to improve one’s athletic performance.
If you or someone you know seems to be struggling with an ED related to being an athlete, it’s important to take action. Talk to your doctor as soon as possible to prevent the situation from becoming worse. Find a therapist and a dietitian who are adept at working with athletes who struggle with EDs. It is also important to alert the sports team’s trainer and coach to the problem, as they will be an integral part of the treatment team. When all of these pieces of the treatment team are in place, the likelihood of recovery is much higher.
In an interview with ESPN at last month’s Major League Baseball All-Star Game, Mark Teixeira, first baseman for the New York Yankees, fielded questions about the gluten-free, dairy-free, sugar-free diet he has reportedly been following since the off-season. Although he nicknamed his set of food rules the “no fun diet,” Teixeira praised his diet for bringing about his return to health and all-star-worthy performance based on his belief that the foods he had eliminated are inflammatory to the body.
Each time an athlete speaks up about his or her fad diet and its associated pseudoscience, life gets a little bit harder for the rest of us. Already, so much of my time with patients focuses on reeducation involving the food myths and misinformation that are so prevalent in our society. The Teixeira interview and others like it add fuel to the fire.
The problem is not that Teixeira has excluded gluten, dairy, and sugar from his diet. This is his body, his career, and his life, and I am in no position to judge him for the choices he makes regarding these entities or for whatever he believes, accurate or otherwise, about food. We all get to decide for ourselves how we want to lead our lives and what we want to believe, and he is subject to the same freedom.
Rather, the problem is how the dietary choices of athletes are framed and conveyed to the rest of us, the incorrect information and insinuations that often come along for the ride, and the bizarre phenomenon existing in our society whereby we put more stock in health advice doled out by celebrities than actual licensed healthcare professionals.
As a general theme, people tend to be more vocal about their dietary successes than their disappointments, which gives us a warped view of reality. Teixeira is not at fault for discussing his diet at the All-Star Game, not when the interviewers made a point to ask him about it. But would his diet be the subject of such conversation if his year was not going so well?
Consider his teammate, CC Sabathia, who lost a bunch of weight (temporarily, at least) after adopting a low-carbohydrate diet a couple of years ago. His diet and its associated weight loss got plenty of media attention back then, but hardly anybody seems to be talking about it now. Perhaps ESPN would have asked Sabathia about his diet at the All-Star Game if he was invited to be there, but as it turns out, he is in the midst of the second worst statistical season of his 15-year career, both of which have come after he went low-carb.
Did cutting carbs and losing weight cause Sabathia’s career to suffer? Possibly, but neither you nor I know for sure. While a correlation certainly exists, causation remains a question mark. Nutrition definitely impacts sports performance, but so does a host of other factors. Regarding Sabathia, elements like age, injury history, and general wear and tear are at play as well, not just his eating and weight.
Just as we cannot scapegoat Sabathia’s diet and lost weight for his poor play, we cannot automatically credit Teixeira’s newfound food rules for his bounce-back season. Perhaps he is simply healthy again for the first time in a long while after undergoing wrist surgery a couple of years ago. After all, except for 2013 and 2014 when he was injured, Teixeira has been one of baseball’s best players for over a decade, and it sure sounds like he was eating gluten, dairy, and sugar during all those years of dominance earlier in his career.
We see these same themes in other sports as well. A televised Novak Djokovic tennis match cannot go by without the commentators throwing in at least one mention of his gluten-free diet, which he credits for catapulting him to the status of number one player in the world. Yet, never once have I heard anybody in the media talk about the eating habits of Roger Federer, arguably the best player in the history of the sport and someone who has continued to compete at an elite level at an age well past when most tennis professionals retire. His diet consists largely of foods like cereal, pancakes, and pasta – in other words, plenty of gluten.
Could it be that Djokovic’s career took off not so much because he cut out gluten, but rather because his years of training, practice, and experience have come together during the window of prime age for a tennis player to produce great results? Similarly, perhaps Federer’s longevity, ability to stay healthy, and years of domination have less to do with pancakes and syrup and are more due to talent, hard work, smart coaching, and efficient mechanics.
If you find yourself tempted to adopt a fad diet because a successful athlete is preaching it, look at the big picture and remember that most of his or her peers are probably not following his or her diet and are also doing quite well for themselves, but their eating patterns are not as sensational and therefore not garnering the same attention.
On a more macroscopic level, challenge yourself to consider how much sense it really makes to be taking nutrition cues from an athlete or any other celebrity. My computer and telephone are essential for my work as a dietitian, and I use them daily, but I only know how to use what I believe works best for me. It would be a mistake to fancy me an IT expert, assume that I really know what I am doing in that regard, and emulate my choices. Similarly, looking to professional athletes and other celebrities as you shape your own eating makes little sense either.
She Said
About two months ago, there was a big buzz on the Internet (and news media) that superstar songstress/actress/business mogul Beyoncé had an “amazing” announcement to share with everyone. The plan was for her to make this announcement to all of her fans on the Good Morning America TV show, and it was going to blow everyone away. Of course, the Internet was shivering with excitement. Could it be that Beyoncé and Jay-Z are having another baby? Does Bey have a new album coming out, and is she going out on tour? Has she discovered the cure for cancer? The suspense was killing everyone!
Well, it appears that all she had to tell us was that she has found the secret to losing weight (and keeping it off) and living a fabulously healthy life. How did she achieve this, you ask? Well, by following a diet, of course! Per its website, the “22-Day Revolution” diet is a “plant-based diet designed to create lifelong habits that will empower you to live a healthier lifestyle, to lose weight, or to reverse serious health concerns.” The diet’s author, “world-renowned exercise physiologist” Marco Borges, is on a mission to help his clients find “optimum wellness” by eating a completely vegan diet. According to Borges, by eating “nutrition-packed” vegan foods, people will be able to “transform their lives, bodies and habits.”
Ugh. Can we please just stop the insanity? Every time a new celebrity announces their latest and greatest diet discovery, it makes me cringe. Given that the majority of my patients are those that struggle with eating disorders (ED), I am fully aware that these diets can be the gateway to a life full of pain and suffering, as most EDs start when one decides to diet. Young girls are especially vulnerable to these celebrity diets because they often put these actresses, musicians, and models on an impossible pedestal. Even though most magazine images are photoshopped nowadays, most young girls are not aware of this and aspire to be as lean and slender as Gwyneth Paltrow or as fit and toned as Kate Hudson.
The fact of the matter is that celebrities are not like the rest of us – they are the minority, not the majority. Even if they did not diet like they do, I doubt that their physiques would be much different than they are now. It’s genetics, pure and simple, and they have “won” in the genetics lottery of life. So, even if you go low-carb like Gwen Stefani or Paleo like Megan Fox, it’s highly unlikely that you will end up looking like these celebrities.
These diets or “lifestyle changes” touted by celebs do much more damage than good. Not only do these diets tell us that we cannot trust our bodies’ hunger and fullness signals (and therefore need to follow food rules to be “healthy”), but they also give us a nearly impossible goal of looking like these celebrities if we eat like them. And if someone is predisposed to EDs, each new celebrity diet is like lighting a match and tossing it into a powder keg – nothing good will come from it.
My advice? Whenever you hear about a new celebrity diet that promises to help you lose weight and keep it off, turn back the clock, or magically cure your health condition, please change the channel, toss out the magazine, or click on another website. Celebrities don’t know what’s healthiest for you to eat – only your body knows that!
On July 19, 2015, I was part of a two-member panel at the Association for Size Diversity and Health (ASDAH) Conference in Boston discussing motivational interviewing. My specific task was to examine the size-based biases that patients often hold toward their practitioners and how best to respond to them using motivational interviewing techniques.
The audience was largely comprised of other clinicians, and as such I shaped my remarks in the context that I was talking with colleagues. Because this information can be helpful for others as well, I have reworked my main points in the framework of talking directly to you, our patients.
Background
In the year between finishing my nutrition degree and earning my license to practice dietetics, I interned at a Boston hospital where I did everything from work in the transplant unit to chop squash in the cafeteria kitchen. It was an interesting year, indeed.
One of my rotations was in the bariatric surgery clinic where two dietitians worked. Because I shadowed both of them closely, I know they were both excellent at their jobs, had virtually the same approach, and taught the same material, yet patients perceived them differently because of their size. Relative to each other, one of the dietitians was bigger and the other was smaller. Some patients looked at the larger one and made comments along the lines of: “Look how big she is! How can she possibly help me?” Meanwhile, other patients referenced the smaller dietitian and questioned, “Look how small she is! How can she possibly know what it is like to be me?”
As a budding dietitian just about to step out into the field, these comments made me look myself up and down and consider, well, what exactly am I supposed to look like then? That question always stuck with me and planted the seed that eventually grew into this piece you are reading now and its accompanying talk, which I nicknamed “Looking the Part”: Patients’ Size-Based Biases Toward Their Practitioners and How to Handle Them.
Practitioners are patients themselves in other contexts, too, so understand that this is not about judgment or one party versus another. For healthcare to be most effective and for us to give ourselves the best odds of attaining whatever the desired outcome might be, patients and practitioners must work together, not oppose one another. We all have incentive to break down the walls of bias.
Other Biases
First, let us give ourselves some context by realizing that patients judge practitioners for other factors that are seemingly independent of size. For example, one study looked at how physician dress affects patient trust and confidence. The researchers found that white coats elicited greater trust and confidence by far compared to scrubs, formal business attire, or casual business attire. In fact, patients indicated they were much more willing to discuss sensitive issues like their psychological, sexual, and social problems based on the presence of said coat.
In another study, white-coat-wearing doctors were also found to be the preference of parents bringing their children to the emergency room. That is, unless their children were there for surgical emergencies, in which case they preferred doctors wearing scrubs, suggesting that perhaps clothing is interpreted as a sign of experience or perhaps expertise.
Other studies have found similar biases related to factors like hairstyle and even whether or not a practitioner wears a name tag, but of course all of these factors are readily modifiable. In other words, while practitioners can restyle their hair, wear different clothing, or put on a name tag if they so choose, other sources of bias are not so easily changed.
For example, a study found that parents selecting orthodontists for their children had significant biases toward young females. Youth was seen as more up-to-date with modern techniques, while females were seen as better at communicating and expressing empathy. While this might be great news for up-and-coming women working in orthodontics, it is not such good news for their colleagues who happen to be older and/or male.
Size-Based Biases
Just like there is not a whole lot we can easily do about our age or gender, our size (contrary to popular belief) is largely out of our hands as well. Let me share with you three of the studies that looked at patients’ size-based biases.
The first study was conducted at Yale where a team of researchers sought to examine what impact, if any, physician weight has on clinician selection, trust, and willingness to follow medical advice. The subjects were split into three groups with each group receiving the same exact survey except for one difference: the physical description of the doctor, who was listed as either normal weight, overweight, or obese in the different versions.
Their results showed that patients had less trust in overweight and obese doctors, were less likely to follow their medical advice, and were more likely to change to a different provider compared to normal weight doctors. In other words, subjects were so shaken by the doctor’s weight that not only were they less likely to follow said doctor’s advice, but they were more likely to switch to another provider. These weight biases remained present regardless of the subjects’ own body weight.
Anecdotally, we see examples of this. A colleague of ours recently told me a story about an experience she had. “I had a patient who was coming to see me to figure out if she wanted to be abstinent from substances. At the second session, she was crying and couldn’t look at me. [The patient said] ‘I have to talk to you about something . . . Look at the size of you. How could you possibly help me?'”
The second study, done at Johns Hopkins, found a different result. The researchers there looked at the impact that physician body mass index (BMI) has on the trust held by overweight and obese patients. Instead of verbally describing the doctors as normal weight, overweight, or obese, as the Yale study did, these researchers used pictograms to convey the same information.
They found that while the surveyed patients generally trusted their doctors, they more strongly trusted dietary advice dispensed by overweight physicians compared to their normal-weight colleagues. The results for other forms of advice, such as exercise advice, were similar, although not statistically significant.
This finding is probably the opposite of what many of you expected. In their discussion section, the researchers suggested that perhaps a patient and his or her doctor being roughly the same size creates some sort of bond of trust, and that is behind their findings. Of course, that is just a hypothesis that would require further study.
Meanwhile, we do see examples of patients who show preferences for larger providers. A fellow dietitian told me about an experience she had where a patient refused to let her intern sit in on their session. “When I sat down to do her session, she told me she was sorry that she asked the intern to leave, but she didn’t want another skinny dietitian telling her she can’t eat more than 1,200 calories and must record everything . . . She was relieved when she saw me.”
The third study was done at the University of Gloucester in the United Kingdom where the researchers sought to determine the influence that sports dietitians’ appearance has on selection and perceived performance. They surveyed 100 competitive athletes from 17 different sports in the United Kingdom and showed them computer-generated images of the same woman that were manipulated to feature her at four different sizes designed to represent BMIs ranging from 23 to 38. The athletes were then asked to rank which of these dietitians they would most like to work with and how effective they believed the dietitians to be at their jobs.
The two images of the dietitian as smaller fared best in both questions. In other words, based on nothing more than size, the athletes were significantly more interested in working with smaller dietitians and assumed those women to be better dietitians.
When I was talking with a fellow dietitian about the topic, he had this to say about how his size impacts his work: ” . . . more than anything I’ve really noticed the looks more than the comments. I can see someone look at my stomach as I talk to them and then back at my eyes. For some people, I can see how their body language changes in a negative way when they see what I look like.”
Discussion
So, back to the question I asked myself as an intern: What am I supposed to look like? The answer, to be quite candid, seems to be: Who knows! Some research suggests that patients prefer smaller practitioners, other research indicates they want larger practitioners, and of course some patients do not care, and they understand that the practitioner’s size has nothing to do with his or her ability to provide quality care.
However, whether the majority of patients prefer me at a particular size, or whether only the minority want me at that size, honestly does not matter too much. The nature of my work is one-on-one counseling, so the only person whose feelings really matter is the individual sitting at the table with me. When I am in an appointment with someone, who knows what feelings or biases he or she might have about my size. Although I need to be cognizant of the likely existence of size-based bias, if I make assumptions about the nature of said bias, then I am being biased myself, and that helps nobody.
If I want to provide the best quality care that I can, then my job is not to try in vain to hit some ever-changing target with my appearance, but rather to create a safe space where we can neutrally and non-judgmentally explore the size-based biases that patients bring into my office. This is where motivational interviewing can be so helpful.
Motivational Interviewing
My fellow panelist, Ellen Glovsky, gave a comprehensive overview of what motivational interviewing is and how it works, while I focused on how it applies specifically in the instances of patients’ size-based biases toward their practitioners.
First, let me draw a distinction between two motivational interviewing terms: resistance and discord. Resistance is known as sustain talk, arguments for the status quo, or reasons not to change. For example, a patient talking with his or her doctor about smoking cessation might say, “Smoking is so relaxing; I’d really hate to give that up.”
Discord, on the other hand, is not an issue of changing versus staying the same, but rather an issue in the patient-practitioner relationship. Think of some of the anecdotes I mentioned. If a patient walks into his or her practitioner’s office and says something along the lines of “How can you possibly help me? Look at you!” we know that discord is present.
When I encounter discord, the first point I try to remind myself of is to remain neutral. Although it is human nature to get defensive if we feel we are being attacked, practitioners must remind themselves that in professional relationships, the focus is on helping the patient, not getting into an argument.
Instead, I use techniques common in motivational interviewing, such as open-ended questions, affirmations, reflections, and summaries, to further the conversation in an effort to learn more about where the patient is coming from. Through the course of discussion, educational opportunities often present themselves. For example, the conversation might lead to the topic of social norms that are off base, such as the notion that one need be a certain size or weight to be healthy.
During these conversations, it can be tempting for practitioners to self-disclose further information about ourselves. After all, if my body is already the topic of conversation, why not throw in more information about it? The answer is because doing so typically does more harm than good. Instead of self-disclosure resolving discord, oftentimes it widens the gap between the patient and the practitioner, which is why I say so little about myself during my sessions and save self-disclosure for my blog.
Summary
The research confirms what many of us anecdotally already knew: Patients do often judge practitioners for their size. However, the specifics of the bias are inconsistent and instead vary from person to person, so it is important that practitioners like myself continue to treat you like the individual that you are and not make assumptions about what you think about our size.
Similarly, I encourage patients to acknowledge and keep in mind two points: (1) You cannot tell anything about how your practitioner leads his or her life based on his or her size with any degree of accuracy. (2) Your practitioner’s size is independent of his or her ability to help you.
If you do have feelings about your practitioner’s size, I encourage you to say so, as keeping it inside might hinder your work. In contrast, bringing it out into the open is an opportunity to learn. The two of you can then have a neutral, open-minded, and non-judgmental discussion about your feelings and point of view and then move forward together.
Nearly two weeks ago, I checked into the hospital for what was supposed to be a relatively minor procedure to address an “extremely rare” complication related to last year’s spinal fusion.
When the surgeon got in there, he unexpectedly discovered that my body had reabsorbed the implanted bone grafts while the rods and screws were loose and moving around. This happens in 3% of cases, he said, and he has no idea why it happened to me, as I do not have any of the risk factors for poor healing. As he delivered the bad news to me upon my awakening, he expressed surprise that I was even able to walk around in that condition.
In response to the situation, he had to completely redo the fusion, making for a much longer recovery than we anticipated. One planned night in the hospital became four. One week of missed work will now likely be three. One month of taking it easy now becomes a season, at least.
Twice I fainted in the hospital, and my blood pressure and pulse dropped so low for no apparent reason that they ran tests to see if I had suffered a heart attack, but really the hardest part of the whole ordeal has been coming to grips with the reality that everything I went through last year I must now do again.
However, the situation has been made easier thanks to the help and support of friends, family, an excellent team of nurses and physical therapists at the hospital, and of course my wife, who is now picking up the slack for me in every facet of our life.
Just 12 days before the surgery, I ran the Mount Washington Road Race and we celebrated at the summit. We thought we were at the top; little did we know we were heading back to the beginning. The lesson: I will never take days like that for granted, as they are never guaranteed to come again.
In my mind’s eye, June 20, 2015 represented the end of an extensive journey back from a major operation. Long ago on the eleventh day of my recovery, I began keeping a log of the daily indicators of my progress, small steps all leading towards this late-springtime Saturday morning in New Hampshire when I would return to racing by competing in the Mount Washington Road Race and, upon reaching the summit, declare my recuperation complete.
Beginnings and endings make for nice stories, but they are sometimes just myths. Even as conditions improve and problems slip into the past, they still exist somewhere. Perhaps that is why alcoholics often still label themselves as such even after decades have past since their last drinks. My back will always demand my attention and vigilance, just as diabetics must continue to practice daily blood sugar management, as opposed to achieving their target A1C values and leaving their endocrinologists’ offices thinking they have wiped their hands clean of the disease. Not that I am complaining or feeling bad for myself; we all know that life could have dealt me a much worse hand.
Next week, I undergo a third back operation to correct what my surgeon terms an “extremely rare” complication related to last year’s procedure. Although I can run up the highest mountain in the northeastern United States, I cannot jog around the block or even go for a walk without significant pain. Go figure.
While this past Saturday was not the metaphorical finish line that I anticipated, the occasion still carried a significance. As I neared the summit, I remembered that exactly 15 months earlier I laid in a hospital bed unable to do anything more than slowly shuffle about the unit with my walker and a back brace. The days that I thought I would actually make it back to competitive racing were vastly outnumbered by the days I felt in my heart that I never would, but I always kept working and accumulating small daily indicators that I was inching back towards my old self.
Effort alone, however, is not enough, and I never would have gotten to this point without the help of many people, including my surgeon, Dr. Jean-Valery Coumans, my physical therapist, Sue Bloom, and most of all my wife, Joanne, who has experienced this saga from spending sleepless nights on a couch in my hospital room to waiting for me at the summit. Literally and figuratively, it was a long way back to the top of that mountain, and I could not have gotten there alone. We got this far, and will go even farther, together.
A patient sent Joanne the following email. “I overheard a coworker talking about food/calories/etc. and noted her saying, ‘We should all be on a 1,500-calorie diet as women.’ For some reason this really got to me and I normally don’t let these stupid comments affect me, especially when I know better. Thoughts?”
He Said
Yes, I do have thoughts about this, several in fact, but for the sake of time and space, I will leave aside tangential issues of practicing dietetics without a license (If someone without a medical license made a statement along the lines of, “As women, we should all be taking [insert name of a medication] daily,” would you be cool with that?) and the virtually-constant propagation of nutrition myths throughout our culture. Instead, let’s focus on just how incorrect this coworker’s assertion is.
Caloric needs are surprisingly difficult to determine. The most accurate method is direct calorimetry, which utilizes a metabolic chamber in which the subject occupies a compartment that measures the heat that he or she emits during whatever state of activity happens to be taking place at the time. Unless you enroll in a research study that involves one of these chambers, you will most likely never gain access to one in your lifetime.
Indirect calorimetry, which involves measuring oxygen and carbon dioxide intake and expulsion, respectively, is less invasive in some ways and easier to utilize. Large hospitals typically have metabolic carts that can perform such measurements in their research laboratories, and lesser models exist for office settings. The tradeoff, however, is accuracy, as even the best indirect calorimetry tools are a step down from direct calorimetry.
Next we have the Fitbits of the world, devices that use algorithms to estimate caloric needs based on a crude set of variables. Dietitians use similar equations sometimes as well, and when I do, I always stress to patients that the results are just rough estimates that cannot and should not be taken too literally.
These equations have numerous sources of error, such as the reliance on subjective measures of physical activity. Anybody can Google how many calories certain activities supposedly burn, but really these numbers are general rules of thumb at best. Running a mile burns 100 calories, we are told, but is this right? What about the size and body composition of the runner, or his or her mechanics? Does he or she have short, quick strides or long, less frequent steps? What about swings of the arms, point of contact between the foot and the ground, head bobbing, or any number of other factors that can influence the results?
One of my patients occasionally asks me how many calories one burns during sex. Unless you get two people to have intercourse in a metabolic chamber, who knows? Even then, the heat generated would pertain only to those unique individuals in that specific encounter, so what do you do, divide by two and make the assumptions that their efforts were equal and that these results apply at other times and to other people as well? Logistical hurdles and the countless variables involved make estimating caloric expenditure a guessing game not just for sex, but for pretty much any activity.
As a consequence, estimates of caloric needs are just that – estimates – and vary widely from person to person. My degree in mathematics reminds me that I like numbers as much as the next guy if not more, and I can certainly understand the appeal of having a short, sweet, and specific target for which to aim, but really the best method to determine your caloric needs is to set quantifiable data aside and look internally to your hunger and fullness signals. Despite all of the proliferating nutrition myths and overarching messages we are taught from childhood on that we cannot trust ourselves regarding food, our bodies are actually pretty good at telling us what and how much they need. We just need to relearn how to pay attention and trust those signals again.
She Said
Ahhh, the 1,500-calorie diet. It’s amazing how some arbitrary number has gotten stuck in the minds of so many people. 1,200 calories is also a popular number. Flip through any of your typical women’s health magazines and you are likely to read that all women should be consuming no more than 1,500 calories per day to be “healthy.” Unfortunately, there really is no such thing as the “perfect” number of calories for each and every person. 1,500 calories (or 1,200 calories or 1,750 calories) is a myth. It makes no sense to say that every woman should be on a 1,500-calorie diet; we all are unique human beings with unique needs.
As I tell my patients over and over – every body has different caloric needs. Age, height, weight, gender, muscle mass, and activity level are just some of the factors that can affect our calorie needs. Even the Mifflin-St. Jeor equation, the equation most often used by most dietitians to determine calorie needs, does not take into account all of these factors. Our caloric needs will vary over our lifespan for a number of reasons. Women who are pregnant or breastfeeding need many more calories, while as we age, we typically need fewer calories. Anyone who has lived with a teenager can attest to the fact that calorie needs go way up during adolescence! When someone is recovering from an injury, his or her caloric needs might be elevated. For instance, the caloric needs of burn patients can be as much as double what the “average” person’s needs are. The best way to figure out what your calorie needs are? Eat as you normally would. If you see no large shifts in your weight (think plus or minus five pounds), you are meeting your calorie needs!
When working with patients who struggle with eating disorders, I try to steer clear of talking about calories. Many of my patients have spent countless hours logging the calories they ate (and burned), and most of these patients would say that they were “obsessed” with doing so. I had one patient who would log her calories daily, and if she consumed more than 1,300 per day, she felt like she had “failed.” Another patient would try to stick to no more than 1,800 calories per day, and if she went over by just a few calories, she would binge because she had “blown it.”
Instead of talking about calories, I try to use the “exchange” system with my patients. Exchanges are groups of foods that have similar nutritional profiles. For instance, a carbohydrate exchange (sometimes called “grain” or “starch” exchange) contains approximately 15 grams of carbohydrate per serving. This might look like an average piece of bread, a ½ cup of cooked pasta or rice or ½ of a large potato. By using exchanges, we can take the focus off of calories and how we need to limit them and instead talk about making sure we get enough carbohydrates, protein, fats, vegetables, etc. Calories have a negative connotation for many of my patients, while exchanges feel a bit more abstract and neutral.
In short, instead of setting an arbitrary calorie goal for oneself, I think it would be much more beneficial to set other goals. Getting five fruits and vegetables per day, being physically active for 60 minutes per day, and eating intuitively would be much better goals (in my opinion) than making sure one never goes over 1,500 calories per day.
