Author Archives: Jonah Soolman

Will

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Yesterday, I received word that a childhood friend of mine died suddenly over the weekend from a brain aneurysm. After processing the news for a few hours, I decided to write a letter to his mother. Everybody deals with loss differently so I could be way off base here, but I imagine that after the immediacy of this tragedy passes, she might appreciate hearing some stories about her son and what he meant to the rest of us.

To all of the patients – children, adolescents, and adults alike – who show up in our office looking to manipulate their bodies in hopes of fitting in and gaining acceptance, and to all of our own family and friends who seek to do the same, it is important to keep in mind that in the end we are often not remembered, respected, and appreciated for what made us the same, but rather for what made us different.

He Said, She Said: Marathon Nutrition

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He Said

When I made the decision to leave behind my career as a research analyst for the U.S. Department of Transportation, I began looking for jobs in healthcare and landed a position working on a clinical trial with a kinesiology professor.

Given her background and expertise in exercise science and her personal interest in athletics, I shared stories of my marathon experiences with her and happened to include that I preferred Coke to Gatorade during long runs. “Ugh, that’s the worst thing you could do!” she disgustedly told me. Actually, no, I had figured out through trial and error that my body best tolerated plain old Coca Cola Classic over any other liquid with which I experimented, so I would argue that drinking Coke was the best thing I could do for athletic performance.

Sometimes, quite often actually, approaches that seem most sensible on paper do not function the best in real life. That is why guidelines are nothing more than their name suggests and should not be treated as gospel. Guidelines are helpful because they give us a place to begin, but I always emphasize to runners the importance of experimenting with various nutrition approaches during training to determine which eating and drinking strategy functions best for them and therefore will be used on race day.

In truth, marathoners take all sorts of different approaches to fueling themselves before and during marathons. Gatorade and water are supplied to the masses at various points along the Boston Marathon route, but the elite runners skip those tables and have their own hydration stations where each of them has a custom-made concoction waiting for him or her in labeled bottles. Some runners, for example, drink flat, non-alcoholic beer. A friend of mine used to eat gummy bears during marathons. Another friend made it through the running portion of his Ironman triathlon by alternately consuming oranges and bananas. As for me, I ran most of my marathons fueled by Coke and pretzels.

When Joanne and I first began dating, I was in the midst of a demanding dietetic internship, and I dealt with the stress by going for long runs on the weekends. Although it was clear that she found my behavior a bit odd, only she could tell you which struck her as weirder: the fact that I chose to spend my Saturday afternoons going for 20-25 mile runs, or the fact that I spent my Saturday mornings driving around and stashing bottles of soda and bags of Oreos in various hiding places along my running route. Just because gels, goos, sports jelly beans, and salt tablets exist and work well for some athletes does not mean they will have everybody running their best.

Commonalities do exist among the various approaches that people take, such as the importance of replacing the carbohydrates, electrolytes, and fluids lost during running, but numerous methods of achieving these nutrition goals exist, and that is where the importance of individualization enters the paradigm. Therefore, when you see or hear of another runner taking a different approach to his or her nutrition than you take to yours, remember that multiple “right” answers exist, and stay true to what you know from experience works best for you. Remain confident: Your training, both the running itself and your nutrition experimentation, has gotten you this far, and it will get you to the finish line, too.

 

She Said

April is one of my favorite months of the year. The winter is over (At least it should be!), little green things start sprouting out of the ground, and the promise of warmer days is ahead. Having been born and raised in Massachusetts, I have also come to associate April with the Boston Marathon. As a little girl, I would walk down to Route 16 with my mom, and we would cheer on the runners as they jogged past us. I was always amazed at how these individuals could just go and go and go. And how many of them there were!

From time to time, the subject of marathon running comes up in my work with patients struggling with eating disorders. Many of my patients are exercise enthusiasts who often have to cut back (or completely avoid) exercise in the early stages of ED recovery. As the individual makes progress in his or her ED, the subject of when he/she can start to exercise again will often come up. Of course, when figuring out whether to clear a patient for exercise, the primary care physician really needs to make the final call. Often this means that the patient should be having his or her vital signs taken regularly, and if his or her blood pressure, heart rate, and weight are routinely found to be in the “healthy range” for a good period of time, he or she may be cleared for exercise.

The word “exercise” can have a number of different meanings depending on whom you talk to. For the average person, perhaps going for a 30-minute walk 3-4 times per week would be exercise. But more often than not, for the person dealing with an ED, exercise usually means much more intense activity for more extended periods of time. That’s where the marathon piece comes in. I have had a number of patients state that they would like to resume (or start) running, not with the intent of managing their weight, but to strive for some goals. Usually, it will start with training for a 5K race, then a 5-miler, then perhaps a 10K. In and of itself, these races aren’t a problem vis-a-vis eating disorder recovery as long as the individual is competing and training due to the love of running rather than trying to control weight.

Sometimes I will have a patient announce the plan to run a ½ marathon with the goal of running a full marathon eventually. This is where things can get a bit dicey. As anyone who has run a marathon can attest to, the act is not an easy one. Although I have never run one myself, I have had people tell me it’s a lot like childbirth – after a period of time, one “forgets” the physical agony and only remembers the joy of finishing. In reality, running a marathon takes a huge toll on the body and can be quite grueling. For someone whose body is recovering from a life-threatening ED, training for and running a marathon can put a lot of stress on an already stressed body.

In general, I would suggest that the individual really delve deep into why he or she wants to run a marathon. Is it for the thrill of accomplishment, to check something off on one’s bucket list? Or is it a sanctioned way to exercise excessively, “permitting” the individual to eat with abandon and maintain or lose weight? Personally, I believe that someone needs to be in recovery for a significant period of time before attempting such a demanding physical endeavor. That period of time depends on a number of factors: How long has the individual struggled with an ED, and how long has the individual been in recovery? Has he/she maintained a healthy weight, heart rate, and blood pressure for a significant period of time? Is the patient’s mindset healthy or weight-centered?

If the individual is determined to be healthy in mind and body and the treatment team supports it, I think someone in recovery from an ED could in fact train for and run a marathon. However, it would be advisable for this patient to continue to engage in regular therapy and see his or her doctor weekly to make sure his or her marathon goals aren’t interfering with continued ED recovery. In addition, this patient should consult with a registered dietitian who specializes in both EDs and sports nutrition to make sure that he/she is getting in the right amounts and types of fuel and hydration needed for running a marathon. As long as the above conditions are met, there is no reason why someone who has struggled with ED couldn’t run a marathon.

Yes, #repealtheseal, but not just in this case

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Much has been made of the Academy of Nutrition and Dietetics’ (AND) decision to place a “Kids Eat Right” seal on Kraft Singles. In the virtual world of Twitter, the #repealtheseal trend is off and running. Yesterday, a colleague of mine emailed me and asked that I sign a petition that would join me with thousands of other dietitians who object to the AND’s decision. After giving the matter some thought, ultimately I did sign, but I did so with hesitation.

When I was on my cross-country bike trip, food was often a source of debate. On one hand, riding our bicycles was essentially our full-time job, and as such our nutritional needs were so enormous that we needed a daily tsunami of protein, fat, and carbohydrate just to keep heading east. On the other hand, we were a charity group on a tight budget. Balancing these competing needs led to tension, arguments, and some questionable choices, many of which I begrudgingly tolerated. Unrefrigerated clam chowder and yellow tap water in Washington? Umm, okay, fine. Expired energy bars bought in bulk at a negotiated discount and fragments of broken glass in my PB&J in Montana? Definitely not thrilled.

But “pasteurized prepared cheese product” instead of real cheese slices in North Dakota? That ticked me off, as the difference in price was so slim that I felt our balance had tilted too far towards finances at the expense of respect for our needs as athletes. So while I am not a huge fan of Kraft Singles for myself, let’s get one thing straight: My objection to the AND’s use of their seal has nothing to do with this specific food.

My objection is not that the AND is endorsing Kraft Singles; my objection is that the AND is endorsing any foods at all. If I found an AND seal on broccoli, I would still take exception, which probably separates me from some of my colleagues and explains why I initially hesitated to sign the petition and risk lumping myself in with other dietitians with whom I disagree on the following point. Good/bad or healthy/unhealthy food dichotomies create more problems than they solve. They move people further away from balance and internal eating cues and push them towards external food regulation and feelings of guilt and self-depreciation. If you see one food on the shelf that has an AND seal, what does that say about the seal-less food next to it, and how do you feel about yourself and your behavior if you choose to eat the latter?

Kraft Singles might not have been my food of choice during long bicycle rides, but I can understand that we as a group made the decision to purchase them because of monetary constraints. Remember that people in our own neighborhoods struggle to afford food on a daily basis. Food pantries, the Supplemental Nutrition Assistance Program (SNAP), canned-food drives, and similar initiatives do not exist just for the heck of it. For some of our neighbors, affording Kraft Singles is the best they can do.

Joanne and I each have patients for whom getting enough nutrition is a challenge for medical reasons as well. A few months ago, I suggested to a father that he pack Starbursts with his daughter’s lunch and I make no apologies for that advice. While I of course understand that candy for a meal potentially has downsides, in the case of this patient and the struggles she was facing, the upsides won out. We have other patients with eating disorders for whom the highest nutritional priority is just eating – period – so they can continue their recoveries on an outpatient basis rather than ending up in a treatment facility due to medical necessity. If we as dietitians limit food choices for patients like these by making them shy away from foods that lack a seal, then we are not meeting them where they are at; we are failing to help them to the best of our abilities.

Furthermore, remember that virtually all of us make choices in life that do not prioritize health, and for many of us that extends to food. Cheese product may not be my personal cup of tea, but some people genuinely love it, and perhaps those same people might turn their heads at the sight of my favorite foods. Attempts to cut out favorites for reasons other than medical necessity often ultimately backfire by triggering overeating. For example, someone may eat slice after slice of cheddar in an attempt to satisfy a craving that one Kraft Single could have quenched at the outset. When we take all-or-nothing approaches and “nothing” proves to be unsustainable, the only alternative we have at our disposal is “all.” The floodgates open, and what could have just been one slice – if we were eating in response to internal cues – turns into the whole package.

Given all of these reasons, just as my colleagues and I stand up to the AND for inappropriate use of their seal, we have to be careful to avoid making this about the specific product at hand and remember that placing a seal on any food – any food at all – is the real issue.

Day 366

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Today marks the one-year anniversary of my surgery. Because my spirits were so dismal in the days immediately following the operation, on day 11 I began writing a log of the small daily victories that marked my healing and recovery. While I was initially unsure how long I would keep it up, I have maintained the log to this day and have no plans to stop, not when I still have so far to go.

One year ago tomorrow, I strapped on my back brace, leaned on a walker, and shuffled slowly from my hospital room to the nurse’s station and back, flanked by my wife and a physical therapist. Due less to pain and more to my fear that the operation had not worked, I cried the whole way.

Going into the operation, I was under the impression that I would not need a brace. When I found out the surgeon was prescribing one, I angrily and defiantly informed the nurse that I refused to wear the contraption. Over time though, I became attached to it. While the brace was at first just a literal support, over time it took on a figurative role as well, sort of like my version of Wilson the volleyball. During the first two months of healing, my brace and I walked for hours and hours together, and during long walks when I was otherwise alone, unsteady on my feet, unsure of my present, and scared of an uncertain future, my brace was always there to keep me upright and give me the courage to keep moving forward.

On day 67, we walked the entire Boston Marathon route together. Shortly thereafter, my surgeon told me it was time to stop wearing the brace. Truth be told, I was sad to jettison my sidekick. Finding the brace by surprise in the house triggers a similar fondness to randomly running into an old friend in the grocery store.

My surgeon was astonished by how quickly I progressed in the first few months after the operation. “You will be back to your crazy workouts in no time,” my physical therapist told me last summer. Turned out she was way off. As I wrote on day 197, we are only somewhat in control of our destiny and life does not always unfold the way we might expect or wish for ourselves.

Setbacks have been plentiful. Activities that my surgeon said should be fine at the time, like swimming, remained intolerable until seasons after his timetable indicated. Some of the bone grafts were unusually slow to heal and for a couple of months we faced the legitimate possibility that they might never fuse. Once I got the green light to resume weight training, I hurt one shoulder, then the other, and had to leave the weight room once again while I rehabbed them. Raking leaves in the November twilight and rushing to finish before darkness, I swiftly walked into my leaf blower, broke my big toe, and ended up in a walking boot. My most recent MRI showed a bulging disk at the surgical site, a highly unusual complication, and the radiating pain down my leg has returned. What can I say, Robert Smith taught me a long time ago that life is neither fair nor unfair.

Before the surgery, I expected that my healing would plot out a linear trajectory with each week being better than the previous one, but quickly I realized that was unrealistic and a setup for disappointment. Real life has its downs, but thanks to good fortune, hard work, and help from many people, it also has its ups.

Although my ultimate goal remains to resume playing competitive tennis and I am working hard in a physical sense to make that happen, simultaneously I am doing my best to prepare myself emotionally for the possibility that it may never come to fruition. Although I remain light-years away from returning to the court, accepting the latter feels much harder – and much less likely – than ever achieving the former. Past opponents and fictitious foes have contract court time in my dreams and we battle it out several nights most weeks, and my wife does not know that I often tear up when I watch her own matches from the sidelines.

Recovery does not end once the surgical site heals. Despite all that has happened in the past twelve months, in some ways I feel like I am still at the beginning of the journey with a long and unmapped future ahead of me. One year ago, I was bawling on a hospital gurney awaiting my turn in the operating room. Today, I went for my first run outside in 18 months. It was slow, short, uncomfortable, and really, really difficult. And it was totally and completely awesome.

He Said, She Said: Supplements

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He Said

As both a practitioner and a patient myself, I support the idea that everybody should have the freedom to pursue the healthcare path that feels right to the individual in question. The same freedom, I believe, should also extend to practitioners to be able to offer the modes of care that meet their own standards of ethical practice.

Approaches often evolve in response to new education and research. Earlier in my career, I worked at a medical center where selling supplements to patients is a significant part of their way of doing business. As I learned more about the science behind supplements and about the industry itself, I grew increasingly uncomfortable with this approach. Because of that background, you will not find any supplements or products of any kind for sale at Soolman Nutrition and Wellness LLC.

During our sessions, the topic of supplementation does occasionally arise, usually brought up by patients who have heard or read that a particular supplement regimen may help with whatever conditions are ailing them. However, we must remember that supplement manufacturers are allowed to make whatever health claims they would like – well-founded or otherwise – on the bottle just so long as they also have the standard disclaimer, “These statements have not been evaluated by the Food and Drug Administration (FDA). This product is not intended to diagnose, treat, cure, or prevent any disease.”

In other words, the claims made on the bottle may be wildly inaccurate and have absolutely no credible research to support them, but the FDA does not have the power to intervene. Generally speaking, regulation within the supplement industry is reactionary, not proactive. Not only can manufacturers say whatever they want about their products, but they also do not have to prove their products are safe before they go to market. The FDA only steps in when a problem arises, as it did in the 1990s when people died from the anti-obesity supplement commonly known as fen-phen.

Furthermore, the FDA does not regulate the contents of supplements themselves, and oftentimes actual products do not contain what is listed on the bottle. Back in 2008, for example, I attended a talk during which a dietitian presented an independent research study that found that the hardly any of the tested protein powders contained the amount of protein advertised on the label. John Oliver, in his funny yet factual breakdown of the Dr. Oz debacle and the supplement industry in general, reveals that one in three supplements contains no trace of the plant advertised on the bottle. “If one in three milk bottles didn’t contain milk,” he says, “you might think twice about pouring the white mystery liquid all over your cereal.”

Even information regarding legitimate substances, such as vitamins, is skewed. Vitamins get their distinction because a deficiency in any one of them can cause a specific disease. For example, vitamin C deficiency causes scurvy, which is one of the reasons why the British navy began providing limes for their sailors in the 1800s. During Europe’s Industrial Revolution, children no longer received the same sunlight exposure as they did in generations past and consequently developed rickets, an indicator of vitamin D deficiency.

However, just because an adequate amount of a vitamin will prevent a deficiency-related disease does not mean that a benefit exists to taking excessive amounts. The United States Department of Agriculture’s Dietary Reference Intakes include tolerable upper intake levels, defined as “the highest level of daily nutrient intake that is likely to pose no risk of adverse health effects to almost all individuals in the general population,” for most vitamins, yet we can easily – and unknowingly – exceed these upper limits through supplementation.

For all of these reasons, unless a patient’s situation suggests the contrary, I recommend doing our best to get our nutrients through food first and only bringing in supplements when necessary. If it does look like a supplement is warranted, I suggest my patient run it by his or her primary care physician.

 

She Said

The topic of supplementation often comes up in my nutrition counseling sessions with patients and their families. Since I am not a medical prescriber, I always refer patients to their primary care physician when it comes to questions about supplements. While I usually suggest that patients try to receive most of their nutrients from actual food sources rather than pills or powders, there is some promising research on specific supplements that may help those struggling with eating disorders (EDs).

As one would guess, those struggling with EDs are usually deficient in many different nutrients due to extreme restriction and/or purging or laxative abuse, and this can compromise every organ in the body. These nutrient deficiencies can lead to a number of medical issues for the individual, including (but not limited to) osteoporosis, anemia, and heart and kidney problems.

Many supplements have been studied in their relation to EDs. For example, zinc supplementation has been linked to improvement in appetite, taste perception, and mood as well as enhanced weight restoration and menstruation in anorexic girls and women. Supplementation with essential fatty acids, specifically EPA and DHA, has also been found to aid in weight restoration while decreasing preoccupation with and anxiety around food in those with anorexia. For those struggling with bulimia, supplementation with electrolytes such as potassium and magnesium is often prescribed due to the large amount of electrolytes that are lost through purging.

A number of my patients struggling with EDs are either vegetarians or vegans, which can result in nutrient deficiencies including calcium, iron, and vitamin B12. Calcium deficiency can lead to osteoporosis, which can be tested for by doing a DEXA bone scan. Iron and vitamin B12 deficiencies can be detected by blood tests. In some cases, supplementation with these nutrients might be suggested to aid in the prevention or management of medical conditions.

At the end of the day, I try to focus on food with my ED patients, as most nutrients are best absorbed from dietary sources. But in some severe cases, supplementation might be indicated if the individual is unable (or unwilling) to eat the foods necessary to attain these nutrients. Refeeding can be a very uncomfortable experience for those struggling with EDs. Most of my patients who are refeeding experience painful bloating, cramps, constipation, and delayed gastric emptying, which can make it feel nearly impossible to eat anything at all. In those situations, supplementation with certain nutrients might be indicated until the individual is able to start eating normally again.

If you are considering supplements for either your own or your child’s ED, please consult with your physician before trying anything on your own. Your physician will be able to assess any nutritional deficiencies through a number of diagnostic tests and then can guide you in the right direction.

The, umm, “power” of carrot cake

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CarrotCakeOn Valentine’s Day, I surprised Joanne by baking her a carrot cake. Just over one week later, I realized half the cake was still in the refrigerator. Although we liked it, we both felt like we had had enough. The cake was getting old and we did not want to take up freezer space with it, so we pitched the remaining portion.

In posting this, I risk the inherent danger of misunderstanding, so let me be clear: Moralizing foods or eating behaviors is a harmful practice that I do not endorse. Carrot cake is not “bad” or “unclean” or a “guilty pleasure,” nor did I “fall off the wagon” when I baked and ate it. We are not “disciplined” for leaving some, nor would I have been “good” if I had never made it in the first place.

Our carrot cake exemplifies a nutrition strategy that Joanne and I oftentimes use with our patients. We often hear people tell us about their trigger foods, i.e. foods they feel must be completely avoided because a little inevitably turns into a lot. They are addicted to these foods, they say, or perhaps they blame themselves and cite a supposed lack of willpower.

The presumed solution is to abstain from these foods at all costs, but the downsides of this approach include missing out on favorite foods, a low likelihood of long-term success, and reinforcing the notion that these foods are taboo, which only serves to make people want them more.

We find that doing quite the opposite works better: Keep large quantities of said trigger foods on hand at all times and give ourselves permission to eat them whenever we want. Patients sometimes bristle when we raise this idea. If we believe a food has control over us, then having it available in abundance feels scary. Furthermore, giving ourselves permission to enjoy it whenever we feel like it sounds ridiculous and counterproductive to the pursuit of health.

I know, I know, we’re crazy, but think about it: Granting ourselves unconditional permission to eat a particular food does not automatically mean we are actually going to eat it regularly or in vast quantities. We may be surprised to find how sharply our desire for a previously-taboo food can drop off once we give ourselves unconditional permission to consume it.

We couple this approach with building intuitive-eating skills, which involves learning to ask ourselves questions about how hungry we are, what food do we really want at the moment (what temperature/color/texture/flavor/etc. do we really feel like), and what quantity of the identified food do we truly need to feel satisfied. If we ask ourselves these questions in a neutral, open-minded, and non-judgmental fashion, the answer is only sometimes going to be the previously-taboo food.

When it is, then we eat it slowly, enjoy it without guilt, and get on with our day. We stop when we have had enough, not when we are overly stuffed, because we know we can have more if and when we want it. The food, in essence, is demystified. Cookies are just cookies. Potato chips are just potato chips. Bread is just bread. We only experience their power over us when we operate in a paradigm that gives them power. When we remove moralization, judgment, and strict rules from the model, the sham of power is exposed for what it is and supposed addictions resolve. The carrot cake is forgotten as it blends in with all of the other foods in the fridge.

Joanne and I keep lots of play foods on hand, much of which we never touch. We have apple crisp ice cream that I bought this past fall in our freezer and Halloween candy in our pantry. We have unopened trays of Newman’s Own cookies and stashes of frozen pastries I made from scratch. We still have Valentine’s Day candy – from last year’s Valentine’s Day.

And none of that makes us “good” or indicates “willpower” or “discipline,” nor are we “bad” or “weak” or “guilty” when we do enjoy these foods. By having play foods on hand at all times, we find that we actually want them less. Remember, carrot cake is just carrot cake. Sometimes it hits the spot, but other times we might just want, well, a carrot.

He Said, She Said: “Do Your Job”

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He Said

The main reason I enjoy following sports is not entertainment, but rather because I am fascinated by how athletics reflect life’s themes with such clarity that the lessons are blatantly apparent. Earlier this month, the New England Patriots won the Super Bowl behind Bill Belichick’s “Do Your Job” command. In other words, perform your role as you are taught, trust that your teammates will do the same, and as a result, the team as a whole will experience success.

This same lesson applies to health care. In fact, practitioners actually use the word “team” when describing the collection of providers who collaborate to help a given patient. This treatment team consists of a primary care physician and any number of specialists, including psychotherapists, dietitians, physical therapists, and others who are all essential to the patient’s care.

Equally essential is understanding the importance of each practitioner doing his or her own job, no more, no less. Nobody is an expert in every single facet of health care; consequently, all providers have limits to their scopes of practice. One of the traits that separates the best practitioners from their peers is recognizing where their boundaries lie and taking care not to step over them.

Unfortunately, some practitioners, who no doubt have their hearts in the right places, exceed these boundaries. Quite often, Joanne and I encounter situations where other members of a treatment team have provided the patient with nutritional advice. The result is almost always confusion and a step backward in the patient’s care.

For example, one of my patients recently told me about different pieces of nutritional advice that his primary care physician and his personal trainer had given him. In both cases, the guidance he received was off base. My poor patient, he was so confused that the result was a temporary undoing of progress he and I had achieved together.

The doctor no doubt meant well. Doctors are absolutely critical in health care. Primary care physicians are trained to be first-line responders for conditions ranging from splinters to cancer. Specialists dedicate their lives to their individual disciplines, and their unique expertise oftentimes quite literally makes the difference between life and death. Personally, I owe an unpayable debt of gratitude to my neurosurgeons, Dr. Griffith Harsh and Dr. Jean-Valery Coumans, for giving me the quality of life that I have now.

However, doctors receive a scarce amount of nutrition education in medical school. According to one study, students received only 23.9 hours on average of nutrition instruction in medical school, which amounts to basically a long weekend workshop. That is almost 24 hours more of formal nutrition education than most people, but still nowhere near what dietitians receive.

During a Google search, I came upon a blog entry a doctor wrote in which he attempted to dispel the “myth” that doctors do not receive adequate nutrition training. He cited the mountains of organic chemistry, biochemistry, and physiology that medical students take in addition to learning about the roles that various nutrients play in the body. However, his argument only serves to prove my point. The hard science is of course important, but so is having a solid understanding and appreciation for how food is complexly intertwined with other facets of life, such as social, cultural, and financial factors. Dietitians, not doctors, receive this comprehensive training, which perhaps explains why so many patients come in here having been given rigid, unsustainable, and plainly unrealistic “doctor’s orders” regarding how to eat.

As a former personal trainer who still maintains my certifications even though I no longer practice as one, I can attest to the important functions that trainers serve. Great trainers can put together workout programs that increase safety, effectiveness, and enjoyment while simultaneously reducing the intimidation, confusion, and boredom that sometimes accompany exercise.

Having been through the personal training certification process and having worked in the field though, I can tell you that most trainers have no nutrition knowledge beyond what most laymen hold. Looking through the manual that I studied for one of my certifications, I see that the nutrition chapter is 15 pages long. As I have argued before, sometimes a little bit of nutritional knowledge is worse than none at all. Registered Dietitians hold degrees in the field, complete rigorous internships that include everything from chopping squash in a cafeteria kitchen to ordering intravenous feedings for intensive care unit patients, pass credentialing boards, and hold state licenses to practice dietetics. Fifteen pages versus all of that. From whom would you rather receive your nutritional guidance?

Similarly, we dietitians have limits to our expertise as well, and we must respect them. Because emotions can be so intertwined with food, strong feelings and deep-rooted issues sometimes arise during our sessions. Acknowledging these emotions and taking them into account are important parts of our work, but we cannot address them as effectively as trained therapists can. For that reason, providing the quality of care that our patients deserve sometimes means suggesting that they consider adding a therapist to the team.

Practitioners of all disciplines fill important roles in patient care, but if we want to achieve victory, which in this case means helping our patients to the best of our collective ability, then we need to follow Coach Belichick’s guidance by staying within our scopes of practice and trusting that everybody else on the team will do the same.

From the patient’s perspective, keep in mind that well-meaning practitioners sometimes reach beyond the bounds of their expertise in an effort to help, but the further he or she stretches, the less accurate the guidance is likely to be. If you want reliable expertise regarding a particular issue, then seek it from a practitioner who has dedicated his or her professional life to that specialty and let him or her do his or her job.

 

She Said

What an exciting Super Bowl that was! Jonah and I were on the edge of our seats for the entire game, and the finale was just amazing! It got us thinking about the Patriots’ motto this season: Do Your Job. It was clear that every Pats player had such an important role in that game and that each player did his job extremely well. In order to work together as a team, they needed each person to execute his job as he had been trained. And it really paid off!

The Pats slogan got me thinking about how eating disorder (ED) patients need a strong treatment team in place in order to recover. Each member of the treatment team needs to do his or her job to support the patient, and there needs to be a clear line of communication among all team members. In addition, each member needs to try to practice within his or her scope of expertise without taking on the others’ roles.

In ED treatment, the team can consist of a number of different players. If the patient is in an inpatient or residential program, the treatment team will likely include a doctor and/or psychiatrist, a nursing staff, a therapist, a case manager, residence counselors, and a dietitian. In an outpatient setting, the team ideally includes a physician, therapist and/or psychiatrist, and a dietitian who specializes in EDs. It could also include teachers, advisors, deans, coaches, and in some cases, the patient’s family as well. You know the saying that it takes a village to raise a child? Well, it takes a village to help a patient recover from an ED.

As much as we try not to do so, sometimes treatment team members will fumble the ball by giving advice that is outside of our scope of practice. I remember one of my patients had a therapist who was actually making changes to the meal plan I had developed for the patient without talking with me first. Although I am sure the therapist only meant to help, it gave the patient mixed messages about what roles the therapist and I would play. Similarly, there are times when my nutrition counseling sessions seem to take on a more therapeutic nature. Most people have a lot of feelings around food, eating, and weight, and sometimes it is difficult to know where the boundary lies between nutrition therapy and therapy! But I always strive to bring the conversation back to the food and then suggest the patient discuss his or her feelings more in depth with his or her therapist.

Another important aspect of treatment team work is that the team usually functions best when there is one quarterback running the show. In most cases, this individual is usually the ED physician or therapist, although sometimes it can be a case manager or even the dietitian. In reality, the patient is really the quarterback, but when he or she is really struggling with ED, a trained professional is the safest bet to step in and manage treatment.

Above all else, communication is the cornerstone of a successful treatment team. Clear communication, whether by phone, in person, or via email, can really make such a difference in a patient’s quality of care. If we are all on the same page, the patient will get a consistent message and hopefully feel more confident and secure that his or her treatment team is a cohesive unit that will help him or her eventually beat ED.

Intuitive Eating

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Thanks to a colleague’s tip, one counseling technique I sometimes implement is a one-on-one book club of sorts where a patient and I read a book together that is relevant to his or her care. Recently, I have been reading Intuitive Eating with a patient who is working hard to overcome decades of approaching eating from the vantage point of dieting and to build a new relationship with food.

He has impressed me by how open-minded he is to a new way of looking at eating and by how candidly he has shared the thoughts, questions, and concerns that have come to mind during his reading. Now about a third of the way through the book, he reports that he sees himself in many, but certainly not all, of the case studies that the authors present. However, the idea of not depriving himself feels scary. Specifically, he notes that he loves having dessert, but that he is better off skipping it because one brownie so easily turns into four. Besides, he says, health must come into the picture somewhere, so there must be a “but . . .” caveat to the notion of not depriving oneself. He is waiting for the other shoe to drop.

His concerns are common among people who are at the early stages of putting aside the dieting mentality and learning intuitive eating. He is right that we certainly consider health. After all, I am a licensed health care practitioner. Before we take into account the hard science of nutrition though, we have to address the emotions that affect eating.

Sure, physiological mechanisms exist that yield pleasure when we consume foods that are high in fat, sugar, or salt. You are alive to read this because these mechanisms gave your ancestors an evolutionary advantage and they passed them down to you. However, the reason that one brownie turns into four has less to do with physiology and more to do with the morality that gets attached to them.

When we experience guilt for eating a particular food or virtue for abstaining from it, these emotions block us from being able to truly experience and honor the internal cues that our bodies give us regarding our eating. We eat the first brownie, feel guilty for having done so, and say “screw it, today is ruined” and then reach for three more. In essence, the idea of not depriving ourselves feels scary because in our minds it translates to opening the flood gates. In other words, brownies all day, every day.

In reality, that is not how the body tends to operate. When we strip away the morality of food and see our choices on a level playing field, we discover that the appeal of previously-forbidden foods drops considerably. Some days we may want an apple for dessert, other days we may not feel like dessert at all. And what if we go through the question tree of asking ourselves are we hungry, how hungry are we, what texture/temperature/color food do we want, do we feel like something salty, savory, or bitter, and how much of that food do we really need to be satisfied, and we determine that a brownie will indeed do the trick? Then we find the best brownie we can get our hands on, eat it slowly, enjoy every bite, stop when we are feeling satisfied, and know that we can have another one whenever our bodies are asking for one.

Ideally, the hard science of nutrition comes into play after this sort of relationship with food is established. We can talk about the advantages of one kind of cereal over another, or one kind of yogurt over another, or what have you, but we have to take into account the human element. Whole wheat bread is probably a better choice for someone with high cholesterol than is white bread, for example, but if forcing down the whole wheat because it has a better nutritional profile on paper is going to trigger some sort of overeating in search of satisfaction, then he or she is probably better off just having the white bread in the first place and getting his or her soluble fiber someplace else. On the other hand, if the two breads are pretty much equally enjoyable, then sure, he or she is probably better off with the whole wheat.

Learning to eat intuitively involves taking a leap of faith that we can largely trust our bodies to tell us what and how much to eat. Reestablishing that trust involves dialing down the noise of guilt and virtue that makes our internal signals difficult to hear. If you find yourself consuming piles of brownies, or none at all, consider whether or not you are truly listening to your body.

You Are Not Tom Brady

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Leading up to today’s Super Bowl, a Boston television station aired a piece examining how Tom Brady, the quarterback of the New England Patriots, eats. The segment teaches us that among other eating behaviors, Brady does not consume any added sugar or processed foods and he abstains from alcohol.

Celebrities often influence our own behaviors, which is the driving principle behind sponsorship deals. Lump me in there as well. When Andre Agassi, my all-time favorite athlete, was endorsing Nike, much of my workout apparel bore the “Just Do It” slogan. Later in Agassi’s career when he signed with Adidas, the logo on my sneakers quickly changed from a swoosh to three black stripes.

Whether consciously or subconsciously, the sentiment we tell ourselves is along the lines of, “If those sneakers [or racquet, or sports drink, or watch, etc.] are good enough for him, then they are more than good enough for me,” or perhaps, “If I use those sneakers [or racquet, or sports drink, or watch, etc.] too, then maybe I can play like him.” It is only natural that the same message may extend to our perceptions of how professional athletes eat, but if you are considering emulating Brady’s diet, think again.

With sport being the primary focus of a professional athlete’s life and so much financially riding on performance, they frequently make choices that would not necessarily be prudent for the rest of us. In a recent conversation, a physical therapist pointed out to me how professionals are quick to undergo surgery and rush through their recoveries, while an amateur with the same injury is more likely to opt for a longer, but safer, rehabilitation program rather than an operation.

In other words, the life of the professional athlete is often focused on the here and now while the long-term risks take a back seat. Look no further than how the National Football League dealt with concussions for decades – largely minimizing the significance of brain injuries and rushing concussed players back on the field with little regard for the depression, memory loss, and suicidal urges that often came with retirement – until very recent legal action inspired change.

This philosophy bleeds into nutrition as well. Following rigid food rules comes with upsides for professional athletes, but similar payoffs are unlikely to exist for amateurs. Therefore, while it may make sense for Brady and his peers to follow strict diets, the same does not hold true for the rest of us. In other words, Brady’s diet may serve him at this stage in his life, but if implemented by one of us, the same eating behaviors may be described as orthorexic.

According to the National Collegiate Athletic Association, 6.5% of high school football players will continue the sport in college, and 1.6% of college players will go on to play in a professional league. In other words, only 0.08% of high school football players will ultimately play professionally. The statistics that they report for basketball, baseball, hockey, and soccer are on par with these figures. Given the extremely high probability that student-athletes will have to make their livings in a capacity other than turning pro, they often have backup plans for their lives (well, at least hopefully they do) in the form of academic educations so they have somewhere to turn when school and their athletic careers end.

Similar benefits exist in thinking long-term about nutrition as well. With all due respect to Brady and other professional athletes who are doing what they feel they need to do in order to perform their best, all-or-nothing approaches to eating rarely serve people for too long. When an athlete retires and suddenly the incentive for restriction ends, how will he deal with previously-taboo foods? This is akin to children who grow up in rigid eating environments with strict rules regarding quantities and/or forbidden foods, and then they go off to college and binge on late-night pizza delivery and all-you-can-eat soft serve in the dining hall. Such black-and-white approaches that teach us to ignore our internal cues and rely instead on external constructs will in all likelihood ultimately backfire.

Real life exists in grays, so building healthy relationships with food means both listening to our bodies and being flexible to allow for the complexities and variables that come our way. A professional athlete may have incentive to sacrifice such a relationship and rely instead on external rules because the here-and-now upside is so great, but the rest of us are better off learning a lesson from the 99.92% of high school football players who will never play in the National Football League. In other words, think long and hard before deciding to sacrifice for the here and now, and instead focus on life’s big picture.

Psychology

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At a large family gathering over the weekend, a distant relative asked me about my work. Upon hearing that I am a dietitian, he smiled, leaned in, and asked me one of the most common initial questions that dietitians field, “So, do you practice what you preach?”

Whenever this question comes my way, I experiment with different permutations and phrasings of the same core truth in order to see which version best resonates with people. In this instance, I told him that what I “preach” might not be what he imagines, and that in reality a large chunk of what I do involves helping people to listen to and honor their internal cues regarding hunger, fullness, and food cravings.

His eyes wandered elsewhere as I spoke, and I could tell that this version of my answer was most definitely not resonating with him. When I finished, he reflected back to me, “That sounds like psychology.” He is not alone in his confusion, as other people have reacted similarly upon hearing a summary of intuitive eating. However, reconsider my answer within the framework of the following examples.

When a diabetes educator discusses the symptoms of low blood sugar with his or her patient, is that psychology?

When a physical therapist instructs a patient on how to modify an exercise in response to pain or discomfort, is that psychology?

When a primary care physician listens to his or her patient recount the side effects he or she experienced on a particular medication, is that psychology?

When a personal trainer talks with his or her client about the difference between the temporary discomfort that sometimes accompanies exertion and warning signs of injury, is that psychology?

Of course not, none of these examples are psychology; they are just examples of various discussions that take place between patients and practitioners regarding the feedback that our bodies give us in particular situations.

Yet when a dietitian engages in a similar discussion with a patient, whoa, suddenly it is seen as psychology. 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?

Dietitians are not psychologists, psychiatrists, or social workers (Well, some are, but the vast majority do not hold such a license in conjunction with their dietetic credentials.) and we know our professional boundaries. Discussions of said internal signals are not only within the realm of our work, they are critical to its success.

Just as my relative expected a more concrete and specific answer that would have put some label on my personal style of eating, new patients often expect that a similar external structure, such as a meal plan or a calorie recommendation, will drive their care. Nutrition is not that simple. In fact, long-term success often hinges on paying less attention to external cues regarding what and how much to eat and putting more focus on the internal signals that our bodies give us. Does that sound like psychology to you?