Author Archives: Jonah Soolman

He Said, She Said: Nutrition in Schools

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He Said

Wellness class. The other freshmen and I thought the class was such a joke that if you told then-15-year-old Jonah that in a couple of decades he would wittingly choose to incorporate the word “wellness” into his business’s name, the cognitive dissonance would have rocked his adolescent world view.

Wellness class was gym without the, well, gym. The teachers were the same, but instead of leading us through units of volleyball, basketball, and badminton, they taught us about health and nutrition. The overarching culture, however, was consistent. Gym was the informal time of day, the high school version of recess. It was a time to let loose, move our bodies to one extent or another, and measure ourselves against our peers, both figuratively and, as you will read, sometimes literally. You had better believe the spirit of competition bled into the wellness classroom, too.

Even at 15, I could tell that the school’s approach to wellness was off base. We used to undergo various exercise performance tests (pull-ups, submaximal cycle ergometer, sit-and-reach) as well as anthropometric exams (weight, height, body composition). All of these evaluations happened in front of the group, so we all knew how each of our peers had fared. Gee, sounds like a great plan; what could possibly go wrong?

After the testing was over and it came time for the teachers to gather us together and offer congratulatory certificates to those of us who had what I suppose were good results in the eyes of the teachers or whatever norms against which they measured us, I crumpled up my award in my hands on the spot. Immediately, I felt guilty as if I had disrespected the teachers who had given it to me, but as time went on, I confirmed that my intuition was right.

If the teachers gave some of us certificates based on our body measurements, what kind of message did they send to all of the other students who did not receive such certificates? As a result, how do you think those students felt about themselves and their bodies? Similarly, how do you think their certificate-holding peers viewed them? The teachers indirectly started the bullying by posting their body mass indices and body composition results, thereby publicly shaming them, and other kids were more than happy to pick up the harassment where the teachers left off.

See, here’s the thing: If a teacher is conveying oversimplified and misguided lessons about how we can manipulate our bodies and our weight based on how we eat and exercise, and then they single out the kids whose bodies happen to be larger, the message they are indirectly teaching is that something is wrong with these larger students, that they are not doing enough to take care of themselves, that they are lazy and/or eat too much. And we wonder how weight stigma forms and gets perpetuated.

I still remember two of the largest kids in my class as well as their body composition results. These data should never have been my business to know. What does it say about the culture the school created that these results have stuck with me all this time? That was not wellness.

If we are going to even consider teaching nutrition in schools, we have to scrap the status quo and reexamine fundamental questions of who will do the teaching, what expertise do they hold, what environment will they create, will they reinforce stigma or break it down, and most importantly, what lessons will students actually absorb about their relationships with food, physical activity, and their bodies. If we cannot provide answers that are worthy of their own certificates of satisfaction, then we should not be teaching nutrition in schools at all.

 

She Said

As the holidays have come to a close, it’s back to reality for most of us. For some of my patients, that means back to school. Lately, it seems like I have been hearing a lot about school-based nutrition programs from my patients. Some of these programs are being run in their health classes, while others are part of their biology curriculum or other classes. It got me thinking about the subject of nutrition and school. Should nutrition be taught in elementary, middle and high schools? If so, who should be teaching it to the students? What should the nutrition course cover?

Given that the vast majority of my patients are those struggling with eating disorders, I have some mixed feelings about nutrition in school. On the one hand, I think it’s important for kids to learn about how to take care of themselves and the consequences of their lifestyle choices on their health. For instance, it makes sense to me for kids to learn about different nutrients and how they can help them grow and thrive.

But I worry that along with this helpful information, the kids might be learning a whole different lesson. From what I’ve heard, many of these nutrition programs are focused on making sure students maintain a healthy weight and actually scare them about the potential dangers of being overweight. As Jonah and I have written about extensively, health and weight are not synonymous; lifestyle behaviors are a much better predictor of health outcomes. This means that even if someone falls into the “overweight” or “obese” categories on the BMI scale, they are not necessarily doomed to poor health. Similarly, someone who falls into the “normal” weight category might not be healthy. It’s the behaviors that make the difference, not weight.

In addition, kids (and adults) come in a wide array of sizes and body types – we are not all meant to be slender. Genetics are a huge determinant of body weight. And as we have noted many times before, diets (or any program or restrictive way of eating meant to alter one’s body size) fail 95% of the time, usually ending up in weight regain. Oftentimes, I hear that school nutrition programs propagate the false idea of “calories in, calories out” in regards to weight. It’s just not that simple.

Unfortunately, the main message that most of my patients glean from these school nutrition programs is “fat = bad” and “these are the foods to avoid in order not to be fat.” In one case, one of my patients told me her biology professor had her students calculate their resting metabolic rates and then keep a food journal to log their calories to later evaluate if they were eating too much to maintain their weight. Another one of my patients told me that she actually learned about eating disorders from an educational video shown in her health class and that’s when her bulimia started. For someone who has the genetic predisposition for developing an eating disorder, these types of messages and activities can actually trigger them to start restricting.

What’s the solution to this problem? One thought I had is that schools could hire a registered dietitian as a nutrition consultant who is well versed in eating disorders and Health at Every Size®. Perhaps that dietitian could run a nutrition program for the students or train teachers to do so. Ideally, I would think the program should be focused on being weight-neutral, helping students embrace a variety of body types and sizes, and not advocating for restricting certain foods. In addition, maybe it would be a good idea to make nutrition programming an optional part of the school curricula, as some parents might not want their child to learn about nutrition in school. Perhaps the nutrition course could be offered as a voluntary program after school hours for those who are interested in it. I’m not sure what the right answers are to these questions, but I hope that as our society becomes more educated about health and weight, things will change in our schools.

Health at EVERY Size

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In response to my recent post about the calories-in-versus-calories-out myth as seen through the lens of my surgical recovery, someone posted a typo-filled response along the lines of, “You would not have posted this if you had lost weight.” He continued with pretty offensive commentary about people of a certain size not having the right to exist, but I will put that aside for now, not because I condone that nonsense, but because I want to focus on what he said in the quote.

His comment seems to be implying that I had hoped to lose weight and therefore I found a scapegoat for my supposed failure. Not true. We must remember that not everybody wants to lose weight. Some people, whether they are large, small, medium, round, slender, or any other shape, actually like their bodies the way they are. Other people may wish for a different body shape, but they understand that purposely trying to manipulate their form is unlikely to work in the long run and comes with consequences.

The commenter also seems to be assuming that I am overweight based on the fact that I shared my blog on the Health at Every Size® (HAES) Facebook page. To be clear, the name of this approach to health is not Health at Some Sizes and Failing Weight Loss Endeavors and Shame For Everybody Else. It’s Health at Every Size, and people of all shapes and sizes understand its importance in healthcare.

Consider the counterexamples we have all heard before: “He is so skinny, he can eat whatever he wants” and “She is a twig already, she doesn’t need to work out.” These weight-centered opinions have nothing to do with health. Being lean does not guarantee good health, nor does obesity guarantee poor health; behaviors do matter at every size.

Consider doctors who make assumptions about patients based on their weights. Prior to my surgery, a handful of the doctors with whom I consulted made incorrect assumptions about my lifestyle based on my size. Some doctors will decline to run routine tests on lean people based on the assumption that the patients are healthy, and some doctors will similarly decline tests for larger people, blame existing symptoms on weight, and instead recommend weight loss. None of these behaviors are about health, either.

A long time ago, shortly after my first back surgery, my neurologist asked me, “Are you exercising at all?” At the time, I was really offended. I was running, lifting weights, and playing tennis. Didn’t I look like I worked out? However, as time went on and I became more educated, I realized his question was spot on. Some muscular people never lift weights, some lean people never do cardio, and some obese people are more active than all of them but happen to exist in bigger bodies. Making assumptions about one’s lifestyle based on his or her appearance is not about health either, and to my neurologist’s credit, he knew it.

HAES is about focusing on actual health no matter what size we are, hence the name. For more information on the the HAES approach to health, check out the Association for Size Diversity and Health, of which Joanne and I are proud members.

Day 305: Calories In, Calories Out

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One of my patients and I continually have discussions regarding the myth of weight control boiling down to calories in versus calories out. In other words, expend more calories than you take in and you lose weight. Consume more calories than you burn and you gain weight. Because he has heard this presented as fact for so long from a wide variety of sources, accepting this as a fallacy is difficult for him.

My lifestyle changed dramatically with last March’s surgery. No racing up mountains during my recovery. No running at all, actually. No swimming either. No weight lifting for several months. Certainly no tennis, not even at a recreational level. My high volume of intense exercise was initially replaced with walking, months and months of just walking. Due to a lack of vigorous exercise, my cardiovascular fitness is deplorable compared to what it was not too long ago.

My eating has changed as well. Since I could tolerate more food in my stomach during a walk than, say, a run, the size of my breakfasts increased. While my food choices are almost exclusively vegetarian for ethical reasons, I reincorporated chicken and beef during the first few months of my recovery to ensure that I provided my healing body with the protein that it needed. Since my surgeon reminded me of the importance of calcium in promoting fusion in the bone grafts, I significantly increased my dairy intake, mainly in the form of ice cream.

What I did not do is weigh myself, track my weight, monitor my calories, attempt to quantify my caloric expenditure, or buy into any sort of nonsense about my weight or fitness level saying anything about my value as a person or my competence as a dietitian.

With all of the radical changes in my lifestyle, do you know how much my weight changed from before the surgery until now? Exactly zero pounds. According to the weights that my doctors recorded at my appointments, I am the same weight now as I was before the operation 10 months ago.

If one pound of body fat is worth 3,500 calories (I am not saying this assertion is accurate, but it represents another myth that continues to float around.) and the calories-in-calories-out theory is true, I would have had to have balanced my energy intake and expenditure within less than 12 calories per day on average for the last 305 days. That, ladies and gentlemen, is impossible.

Yet the calories-in-calories-out ridiculousness is not widely recognized for what it is. Recently, someone posted on Facebook a printout that her doctor gave her containing weight loss advice. “Change your diet,” it says. “Eat 500 fewer calories a day. This can lead to weight loss of one pound per week.”

PrintoutIn nutrition, sometimes a little bit of knowledge is worse than no knowledge at all. The notion that calories in versus calories out dictates weight is nutrition 101, but what they tell you in nutrition 102 is that it is not really true. It has some merit as a general concept, but it should never be taken literally, as weight regulation is vastly more complex than that.

During my recovery, I have moved my body in the ways that have felt most comfortable at the various stages of my healing and consumed the foods that my body seems to be asking for in the quantities that are satisfying. When I have missed the mark by overeating, for example, I do not feel guilty or beat myself up; rather, I look at the episodes as learning experiences to figure out what happened and what I can do differently in the future.

Because of these behaviors, plus genetics and other factors that are out of my hands, my weight has happened to stay the same. If it had changed, would I have cared? Sorry, I know this might be hard to believe in the context of our weight-obsessed culture, but my interest is elsewhere.

My plan is to make my comeback to competitive racing at this June’s Mount Washington road race. This is where my attention is focused. I have five months to ramp up from virtually no running to racing 7.6 miles up the highest mountain in the northeast. Can I do it? We’ll see. But I can tell you this: I am excited and looking forward to the challenge.

Coca-Cola Classic Nonsense

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A pretty hefty portion of session time is spent clarifying misinformation that our patients have absorbed from various sources and assumed to be true. If you are a dietitian yourself, you know exactly what I mean.

It can be frustrating, but the patients are not to blame. If I encounter a post or article about combustion engines, overseas investing, the rise and fall of the Ottoman empire, or any other of the millions of topics in which I am a layman, I might mistakenly assume that what I am reading is correct, too. Without expertise in the subject, how could I possibly be expected to decipher the difference between fact, half-truths, and pure fiction with any degree of accuracy?

As an example of the nutrition-related nonsense that circulates in our culture, consider a post that popped up in my Facebook feed today entitled “This Finally Convinced Me to Never EVER Drink Coke Again. Once You See It, You’ll Understand.”

No way am I going to link to it; the post already has thousands of Facebook likes and I am not going to facilitate more exposure. If you really want to find it, I am sure Google will be more than happy to assist you in your efforts.

The post begins with Coke bashing. “The sugar content in each serving is astronomical, and the acidity can strip metal (coke is often used to de-grease car engines). If you’re a big fan of coke and still need some convincing to quit your bad habit, check out this experiment.”

Look, I am not arguing that Coke is a health food, but good-bad food dichotomies create way more harm than people realize. All foods have their pros and cons. Yes, even Coke has its upsides. Otherwise, why would anybody ever buy it?

“What happens when you drink some coke after drinking milk or eating a dairy product?” They continue, “You’ll be totally disgusted to see what happens in your stomach.” A series of photos then depict a small amount of milk being poured into a bottle of Coke, which is then capped and left to stand for six hours. By the time the hours elapse, the mixture separates into an upper layer of tan water and a lower layer of brown sediment, similar to how Italian salad dressing separates when left to stand undisturbed.

The caption reads “But what is that totally gross thing at the bottom? Is it dirt? Sand? Colon cancer?” They aren’t done. “The coke is so acidic that it denatures the protein found in the milk, causing this chemical reaction.”

According to an article published by the American Society for Microbiology, Coca-Cola Classic has a pH (which is a measure of acidity) of 2.5. You know what else has a pH of approximately 2.5? Your stomach. According to the National Institutes of Health, our stomachs – when empty – have a pH in the range of 1.5 to 3.5 due to the presence of hydrochloric acid, which is a naturally-occurring chemical that our stomachs secrete. Good luck digesting your food without it.

In other words, put protein in your stomach, let it sit there for six hours (which is unrealistic, as the stomach tends to empty much faster than that), and the product may very well resemble the denatured milk protein in the Coke bottle. The authors want us to think that something abnormal, scary, and unhealthy happened to the milk, but that is really not the case.

But what fun would it be, and more importantly how many Facebook likes would their piece get, if the authors concluded it with a lesson on digestive system physiology? Instead, they played the fear card. “This is so gross, I can’t believe I put this stuff in my body. Please share this with others, everyone needs to see this.”

No, not really. As it turns out, I don’t think anybody needs to see it.

“Beauty Work”

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This morning I read an article on “beauty work,” the digital manipulation of actors and actresses in movies and television to alter their appearances. No matter how rampant this practice may or may not be, the larger point is that comparing ourselves to people we see in any form of media, or even in real life, is never a good idea.

Joanne and I love the town in which we practice. She grew up here while I grew up just one town over and used to work at a sporting goods store a block from where our practice now stands. One of the challenges of our town, however, is the widespread focus on appearance and the negative fallout that this behavior spawns. Because the latter often shows itself in the form of eating disorders and disordered eating, we set up shop here in order to fill the need for help.

Quite often, patients come into my office and compare themselves to others, but the points of comparison go beyond actors and actresses and more often focus on fellow residents they see in the community. No digital manipulation there, but still, what are they really seeing?

Unless someone is completely candid with us, we never really know what he or she does or does not do to look a certain way. How do you know that the person who just lost a tremendous amount of weight is not battling a serious disease? Are you really sure that the friend you admire for being supposedly naturally slender is not struggling with anorexia, or that the co-worker you praise for eating the perfect little lunch is not later secretly bingeing on pizza and cupcakes before purging? Do you ever consider that the super buff weight lifter might be on steroids, or that the gym rat who can seemingly go for hours on the stair climber might be ignoring a slew of overuse injuries?

How sure are you that the person whose body you wish you had is any more happy, satisfied, comfortable, or confident with his or her body than you are with your own? Do you recognize the very real possibility that he or she is looking back at you with envy as well?

We never really know what is going on with someone, whether they are on a movie screen or walking down the sidewalk. Given that someone’s appearance tells us nothing about the person other than what he or she looks like, and given the negative consequences that frequently arise from comparing ourselves to others, how is it ever a good idea to make such comparisons?

Doctors’ Views on Weight and Weight Loss

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Last week was the Cardiometabolic Health Congress, an annual event for which experts from around the world convene in Boston to discuss the latest developments and treatments for cardiometabolic conditions, such as diabetes, high blood pressure, and high cholesterol.

This was my third year attending the conference, and while I found the first two experiences to be largely interesting and pleasant, this time I had moments of anger and disgust so heightened that I occasionally considered getting up and leaving. If I want to fancy myself as having an open mind though I actually have to live it, not just pay the concept lip service and then bolt as soon as a presenter says something with which I disagree. I stayed, listened, and considered what the speakers had to say.

Following this paragraph is my list of key moments from the conference. By default, I was going to group them by disease state, but given the circumstances perhaps it is more appropriate to categorize them by the emotional state they created.

 

INTERESTING

• Gut Microbes A presentation on gut microbes revealed the immense impact they seem to have on body weight. Linda Bacon addresses this topic in Health at Every Size, and I found it interesting to learn more from a professor who made research in this realm the focus of his PhD work. In experiments he did on mice, he found that animals colonized with the microbes of an obese donor developed twice as much body fat as those colonized with microbes from lean donors, even though the recipients consumed the same diets and had the same initial weights and body fat percentages. Gut microbes seem to be so closely related to weight that he said he can predict one’s body mass index based solely on his or her gut microbes with 90% accuracy. He stressed that this is a developing field and nobody knows for sure yet how to take these research findings and clinically apply them.

• Eating Pattern A presenter stressed that overall dietary pattern is what matters for cardiometabolic health and that no individual foods should be considered “good” or “bad,” a point with which Joanne and I completely agree. All-or-nothing approaches may be popular, but balance and moderation are typically the keys to long-term success.

• “Diet can be so rarely effective in maintaining weight loss.” During his presentation, a bariatric surgeon acknowledged, “There is weight regain in every intervention,” even after surgery, and that body fat seems to have a set point just like red blood cells and the liver, both of which will regenerate to their original masses after partial removal. For that reason, he explained, “Diet can be so rarely effective in maintaining weight loss.” We already know this latter point, but it was interesting to hear a doctor say it. He seems to be moving the focus of his surgery away from just weight loss and instead focusing on the metabolic benefits that can occur after bariatric surgery even in the absence of weight change.

• Effects of Sleep Deprivation on Hunger A doctor who specializes in sleep presented research indicating that the risk of developing cardiovascular disease inversely correlates with sleep duration. In other words, the more sleep one gets, the less likely one is to develop cardiovascular disease. He also presented epidemiological data showing that the less sleep people get, the more likely they are to have a higher body mass index. He debunked the theory that people who get less sleep eat more simply because they are awake for a longer duration. Rather, people eat more when deprived of sleep because leptin and ghrelin levels change and increase appetite. His research found that people consume 35 calories/hour more when sleep deprived compared to when they are adequately rested.

 

STARTLING

• Aspiration Therapy A novel bariatric surgery of sorts, known as aspiration therapy, was presented. The procedure involves implantation of a tube through the abdomen and into the stomach, sort of like a PEG tube that is used for nutritional support. In this case, however, the tube is not used to feed the person, but rather to empty the person’s stomach soon after he or she has eaten.

It’s interesting, if I diverted food back outside my body soon after eating in order to keep it from being properly digested and absorbed, I would probably be diagnosed with the serious and sometimes-fatal eating disorder known as bulimia nervosa, but I guess if the behavior is performed via an implanted device and endorsed by a doctor in the name of weight loss then everything is cool, right?

 

DISAPPOINTING

• FDA Oversight On the conference’s second day, the woman sitting at the table next to me struck up a conversation at lunch time. Turns out that she works for the U.S. Food and Drug Administration (FDA) and part of her job is to keep an eye on the messages that drug companies are using to endorse their products. She explained that when she went into the exhibition hall to speak with vendors, she kept secret that she works for the FDA because if she revealed it then the drug company representatives would “shut up” and warn the other reps to keep quiet because the FDA is there. If the drug companies are telling the truth and not doing anything improper, then why do they care that the FDA is present? Reminds me of how I reflexively hit the brake with my lead foot when I spot a police car on the highway.

• “I just push them all to surgery. I don’t know if that’s a good thing.” During a break, I approached one of the doctors who had presented on hypertension and asked her a question about the effect of sodium lost through sweat. The conversation segued to sports nutrition and then ultimately to weight. She brought up the supposed benefits of losing weight for cardiometabolic health, to which I responded by sharing how dismal the odds are of keeping off intentionally-lost weight. While I expected resistance, instead I got agreement. “It’s biology,” she said, “The body is really good at gaining weight, but not very good at losing it.” While I was pleasantly surprised to hear her acknowledgement, this anecdote ends up in my Disappointing category because of what she said next, “I just push them all [my patients] to [bariatric] surgery. I don’t know if that’s a good thing.”

 

FRUSTRATING

•  Success? Two doctors presented on lifestyle interventions for weight loss. Every single graph they presented for each intervention showed sharp initial weight loss followed by slow and steady regain. With the exception of one four-year study, all of the others lasted two years at most. As the study timelines came to a close, the graphs showed that subjects were still regaining weight, yet the presenters called the interventions successful because the subjects weighed less as the studies ended than at baseline. But the subjects’ weight trajectory was still upward; aren’t they at least a little bit curious about what happened to their weight after the studies ended?

Apparently not, for one of the doctors continued, “As long as you keep the diet and exercise going, you will maintain the weight loss.” But we know that is not true! People often regain weight even as they maintain the behaviors that lost it. Even the doctor I mentioned earlier, the one who pushes everybody to bariatric surgery, acknowledges this.

• Medical Recommendation or Disordered Behavior? The presenters advocated people weighing themselves daily, knowing exactly how many calories they are consuming, and burning at least 2,500 calories per week through exercise. They also suggested that people get together in weight-loss groups for the “healthy competition” of inspiring each other to lose more weight. You know, if lean people did these same things we might describe their behaviors as disordered.

The above point reminded me of an excellent piece that Ragen Chastain wrote about how behaviors that are considered dangerous for thinner people are routinely recommended for heavier people. Trying to keep that open mind I mentioned earlier, I thought to myself that plenty of medical interventions exist that would be cause for concern if someone without a warranting condition began to utilize them. For example, if I prick myself with a needle until I bleed people will probably be concerned about my emotional well being, but a diabetic who does the same thing in the name of checking his blood sugar is taking good care of himself.

The crux of the issue, therefore, is whether or not obesity in and of itself is really a disease. Despite all of the evidence to the contrary, much of the medical community still sees it as one so they advocate treatment for it. We could debate obesity’s place as a disease state all day long, but even if it is one, the problem is the “paradigm blindness” that I mentioned in an earlier blog entry: The presumed solution, dieting, actually exacerbates the condition so they keep adding more of the supposed solution to the ever-worsening issue not realizing they are caught in a feedback loop.

• Can’t See the Forest Through the Trees A doctor presented some research that looked at the influence of lifestyle behaviors (eating patterns, physical activity, stress management) on cholesterol and blood pressure. Researchers controlled for weight by screening out subjects whose body weight increased or decreased by more than 3% over the course of the study. They made this decision based on the presumption that excess weight itself is harmful and would confound the data. What the research showed, however, is that the lifestyle interventions themselves improved blood pressure and cholesterol even when no significant weight change took place. I would have thought the researchers would use these results as a basis for reconsidering the generally-held assumption that being overweight/obese is harmful, but interestingly they did not.

 

HORRIFYING

• Yay, Surgery for Everybody! The U.S. Preventive Services Task Force (USPSTF) recommends screening all adults for obesity. “Clinicians should offer or refer patients with a body mass index of 30 kg/m2 or higher to intensive, multicomponent interventions.” The presenter who shared this continued that USPSTF’s recommendation is a grade-B level. He was excited because he said that the Affordable Care Act mandates that all grade-A and grade-B recommendations be covered, meaning that the USPSTF’s recommendation opens the door for individuals to receive pharmacotherapy and bariatric surgery based solely on their weight. The presenter continued that he looked forward to a day when everybody with a body mass index over 30 kg/m2 could get bariatric surgery.

And there it is. Ever since obesity was officially declared a disease, I have heard people talk about how this controversial decision was about finances. Although I did not know enough about the decision-making process to have a solid opinion, I always leaned away from conspiracy theories and figured that those involved in the decision had not fully considered the overall body of research. Given this statement though, I must acknowledge that it sure does seem likely money played at least a part, if not a large part, in the decision. While other moments from the conference made me more angry, as you will soon read, no other instant made my stomach drop like this one.

 

INFURIATING

• Is Weight Cycling Funny or What!? One of the presenters who discussed lifestyle interventions for weight loss concluded his presentation with what I guess was supposed to be a joke, “Better to have lost and regained than to never have lost at all.” That offensive and ignorant comment garnered huge laughs from the audience. Weight cycling (“yo-yo dieting”) is associated with everything from diabetes to depression. Hilarious! Association is not causation, but he should have at least acknowledged the potential dangers of weight cycling and shown some respect for the people who have gone through it. Instead, he literally used it as a punch line.

• It’s All About the Money During a break between sessions, I visited the exhibition hall and wandered over to a table where sales reps were pitching a medically-supervised weight-loss program that physicians can license for use in their clinics as a way to make more money. One of the reps told me that the patient’s first visit is with a “salesman” (Yes, that is actually the term he used.) who asks the patient how much weight he or she would like to lose and then tells the patient how many visits and injections he or she will have to receive to achieve it. Injections? Those would be phentermine injections, which the Mayo Clinic cautions, “Phentermine may be a way to kick-start your weight loss. But once you stop taking it, you’re likely to regain the weight you lost . . . . Although phentermine is one of the most commonly prescribed weight-loss medications, it has some potentially serious drawbacks,” and then continues on to list its side effects.

Presumably the program also includes dietary counseling, so I asked the rep who is responsible for helping patients with their eating. “Dietitians are too expensive,” he said, not knowing that I am one myself. He said they recommend using “lower level” workers, like “nutritionalists.” I have never even heard of a nutritionalist and have no idea what one is. So far, everything the rep had told me was about sales and finances, so I asked him about outcomes. He had no data to offer me about how patients fare on the program and said he would email me some, but he never did. The rep could not even anecdotally offer any information regarding results. My impression was that little consideration was given to health and patient welfare in this program that seemed to be all about making money.

• Question Dodging This year, the conference organizers diverted from the normal format of having attendees verbally offer their questions through stationed microphones and instead invited us to submit our questions via text. The last event of the conference was a panel discussion on obesity, so I texted in the following question, “Research compiled by Linda Bacon in her book Health at Every Size and Ellen Glovsky in her book Wellness Not Weight show (1) long-term research that looks at least five years out shows that only 5% of people who intentionally try to lose weight keep it off and 60% of them end up heavier than at baseline (2) research that controls for behaviors indicate that these are better predictors of health than is weight. Given this, ethically how can we be prescribing weight loss to our patients?”

The moderator never presented my question to the panel. I could give him the benefit of the doubt that perhaps a technical glitch kept my question from entering the cue, but I received a reply confirming that they received my text. I could give him the benefit of the doubt that perhaps they ran out of time, but in fact the question-and-answer period ended earlier than scheduled.

Perhaps the moderator did not want to address my question because one of the conference’s industry sponsors is launching an anti-obesity drug that is pending final FDA approval? There I go with conspiracy theories of my own. Perhaps the moderator had a legitimate reason for not fielding my question, but it was hard to escape the feeling that he was dodging it.

 

MADE ME WANT TO THROW SOMETHING

• A Seed Is Planted Fortunately, somebody with a little more clout than myself raised a similar concern. A member of the panel, a bariatric surgeon, interjected the proceedings with a question of his own. “Sometimes we do surgery too much,” he began, and cited obese patients who are metabolically healthy, yet have bariatric surgery anyway. He continued that over the course of the conference, research had been presented indicating that lifestyle interventions that address eating, physical activity, and sleep can improve cardiometabolic health even when no weight loss occurs, that even bariatric surgery can have positive metabolic effects independent of weight loss, and people who are overweight tend to fare better than leaner counterparts when battling certain diseases. Given that, he asked, “Are we overemphasizing weight?”

I heard a couple of chuckles, but otherwise the room went silent. Crickets. Nobody on the panel wanted to touch the question. Sensing the uncomfortable silence, the moderator said we would come back to the question and moved on to other topics. The surgeon reiterated his question, this time rephrasing it so as to suggest that the presumed link between weight and health might be inaccurate. Fellow panel members trickled out answers: The exercise specialist said that excess weight can make movement difficult, the surgeon himself said that surgery can be more challenging in the context of obesity and specifically mentioned transplant operations, and another doctor offered, “Some individuals are genetically predisposed to have more adipose tissue . . .” before trailing off. Another surgeon on the panel, who seemed angered by the question, emphatically called attention to the association between obesity and cardiometabolic disease.

At that, the moderator cut off the discussion and moved on to other questions. There it was, one of the most important questions of the entire conference, a question of which I had tried to raise a different permutation myself without success, offered by an open-minded panel member, yet the moderator quickly dismissed it before it received the full attention that it deserved. I found myself literally shaking my head at the missed opportunity.

The upside though is that at least the question was raised. Even if it did not receive a proper discussion in response this time around, the seed was planted, and in that action exists the potential for growth.

Ed

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Earlier today I found out that one of my former tennis partners, Ed, passed away. While I was at a conference (more on that in a future blog entry), a presenter made a comment that reminded me of Ed, so I took out my phone and googled his name thinking that perhaps I would find his Facebook page. Instead, I found his obituary.

When I was in the process of making my second of two comebacks following my initial back operation, Ed was one of a small handful of players who were gracious enough to help me integrate into the local tennis community. My game at that point was covered in rust and I would not have blamed Ed for distancing himself from me, but instead he invited me to become a regular in his twice-weekly games. He and I played doubles together on Wednesday and Sunday nights for years. No matter who won, we always had fun. Those nights comprise some of my favorite tennis memories.

Tennis aside, Ed had a greater influence on my life than he ever realized. In fact, I mentioned Ed in passing in a previous blog entry. Out of everybody I played tennis with, Ed was probably the skinniest. He also happened to be, at least to my knowledge, one of the sickest. He suffered a mild heart attack soon after we began playing together and I came to find out he was also diabetic. He later died of cancer.

Like many people in our society, I held a weight bias without even realizing it. How could a man so lean have diabetes and cardiovascular disease? Aren’t those conditions reserved for obese people? When Ed revealed his conditions to me, I had to reconsider the stereotypes I was holding, the first step of which was to acknowledge that they were, indeed, stereotypes.

My mind opened: Weight does not equal health. This notion has since been further compounded by many sources, including formal schooling, clinical experiences, research, and collaboration with colleagues.

But while many other influences came after him, Ed planted the seed, and I owe him a great deal of gratitude for that. Whenever I help someone shift away from weight stigma or I hit an unreturnable lob over my opponent’s head, I will be sure to remember Ed and say a quiet thanks for all that he taught me.

Preaching Beyond the Choir

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“A lot of people have anti-racist groups. They get together and meet and have a diverse group and all they do and sit around and talk about how bad discrimination is. Then someone says ‘there’s a Klan group across town. Why don’t we invite them to come and talk to us?’ and the other person says ‘Oh no! We don’t want that guy here!’ Well, you’re doing the exact same thing they are. What’s the purpose of meeting with each other when we already agree? Find someone who disagrees and invite them to your table.”

– Daryl Davis

Joanne and I certainly have company among many practitioners across the globe who have abandoned weight-centered models of care for health-centered approaches. We congregate virtually in communities like Health at Every Size® and the Association for Size Diversity and Health. While these resources are important for building support and sharing best practices, we run the risk of only preaching to the choir if we confine our communications to people who are already on the same page as us.

Many practitioners and activists, like Ragen Chastain, Aaron Flores, Ellen Glovsky, Kerry Beake, and Linda Bacon, just to name a small handful, have been putting themselves out there, subjecting themselves to everything from ridicule to blatant hate, as they share research and perspectives that run counter to widely-held beliefs about weight and health.

As for me, while I do not consider myself part of any sort of crusade and prefer to influence change on a one-on-one basis with the patients who come to meet with me, I increasingly feel an obligation to step up to the plate when opportunities to share my perspective arise. Silence is easier, but I fear that it comes across as support for the status quo, so in essence my passivity makes me part of the problem. I need to change that.

A sales rep emailed me in August trying to get me to use his company’s product at our practice. He made some statements about weight that sounded ridiculous, but I ignored his email. In September, he emailed me a second time, and once again I did not write back. When he emailed me for a third time last week, my conscience compelled me to engage him in conversation and confront him about his statements. An email exchange ensued. Following are some excerpts.

Sales rep: “Take a moment to consider all that you can do with [product name] as your tool. You are given a list of the top 5 foods in 7 different categories that will allow an individual to reach their goals the faster than any other foods. This means losing 6 lbs a week and not 2 lbs. Or gaining 5 lbs a muscle the first month of training, instead of a mediocre 3 lbs. If your clients were able to see this amount of increased results and you were able to make more money in the process, don’t you think you would be interested?”

The underlined passage, which I underlined for emphasis, set off my BS alarm.

Me: “Thank you for your email; however, our businesses seem to be on different pages so I do not envision us working together. If you have any research to support the claims that [company name] is making I would be interested in taking a look at it.”

Sales rep: “I would be happy to provide you with literature on the claims our diet plans make if you would like. We have scraped from thousands of published articles.  Is there any specific topic that would be of interest to you?”

Honestly, at this point I was fairly certain that no such research existed, as I probably would have heard about it by now if it did, but I wanted to keep an open mind, and I also felt like this guy was George Costanza lying about a house in the Hamptons and I wanted to see how far he would go.

Me: “Thanks for your email. In your previous email, you talked about weight loss/gain results with [product name] versus without it. I’d love to take a look at that research.”

Sales rep: “Well as you know, weight loss and weight gain is majorly dependent on the amount of Calories consumer and burned over a given amount of time. What we have done is scraped many articles that claim increased weight loss or weight gain when matching a SNP to a certain macronutient profile of a food. We have also analyzed research that observed increased energy levels and increased activity levels in people who ate a majority of the food we recommend. If you’re referring to clinical trials where [product name] users and blinds are closely observed over a period time, we have not conducted a controlled study. One reason being the difficulty that diet research usually has with compliance. The second reason is we believe we can access enough data from the people using [product name] and we will be able to quantify all our results. I personally have lost over 30 lbs in the last 2 months since I started to flow a [product name] approved diet plan.”

Did you catch that? Despite the specific claims that he previously made about the weight-change results that his company’s product supposedly creates and despite his offer to provide me with the research to back up said claims, when pressed he admitted to having no such research.

Me: “Thanks, I appreciate the explanation. It is important for us to remember though that losing weight is relatively easy. Virtually any kind of restriction will create it. Data presented at last year’s Cardiometabolic Health Congress, for example, compared the results of over 20 different diets and showed that all of them resulted in the same weight loss pattern. The problem though is that all of them also resulted in the same weight regain pattern as well. Most studies that look at weight loss only look at the short term, but those that look at least five years out show that approximately 95% of people regain the lost weight and most of them end up heavier than they were at baseline. Sure, some of that is due to people not maintaining the behaviors that created the weight loss, but what I find very interesting is that many of the people who do maintain the behaviors experience weight regain as well. My clinical experience mirrors what the research indicates, as I have certainly had individuals who are so frustrated because they are working so hard to keep off lost weight, and yet it slowly creeps back on. For all of those reasons, we take the focus off of weight and instead focus on behaviors, which research shows are better predictors of health outcomes than weight anyway. Although the public is generally still hyperfocused on weight, we are seeing a slow shift in the medical community away from a weight-centered model of care to a health-centered model of care as more and more practitioners are becoming aware of the research.”

Sales rep:

That’s right, he did not write back, at least not yet. For the sake of fairness and completion, I will update this entry if and when he responds, although I am not holding my breath waiting for a reply. Most likely, he crossed me off his list when he realized he would not get any business from me and he has moved on to other sales leads without giving my latest email a second thought.

On the other hand, perhaps – even for a brief moment – I got him to rethink his stance and consider another point of view. Either way, at least I did not exacerbate the problem by staying silent.

He Said, She Said: Halloween Candy

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He Said

Halloween is when I first learned the meaning of the word “nauseous.” After returning home from trick or treating, I sat at the kitchen table eating candy until I no longer felt well. “Do you feel nauseous?” my mom asked. A loose definition formed in my childhood mind: Nauseous (adjective): Feeling completely gross from eating too much Halloween candy.

My brother, in contrast, always paced himself. While I blew through my own candy in a few days tops, he made his candy last for weeks, if not months. Eventually I realized that eating small amounts of candy at a time not only spared me from feeling nauseous, but the candy lasted longer. Preservation became fun, and at some point I started freezing candy. As springtime flowers bloomed, I would be eating last fall’s frozen Snickers.

Upon returning home from trick or treating, my brother and I dumped out our candy sacks, sorted our bounties into piles by kinds of candies, and traded with each other so we each had our favorites. In order to make our trades with each other, we each needed a foundational hierarchy of our candy likes and dislikes so we each knew which pieces we wished to keep and obtain more of and which ones we hoped to trade. In other words, we had to mindfully eat our candy in order to assess enjoyment.

Halloween and its associated candy provide opportunities for children to build their relationships with food. The healthiest relationships are built on a foundation of internal-cue recognitions and responses: having the ability to not only ask ourselves questions like “Am I hungry?” “How hungry am I?” and “What is it that I really want?” but more importantly, to be in touch with our bodies enough to be able to appropriately answer.

Building these skills involves trial and error. As I did on that Halloween so long ago, sometimes kids overeat and regret it. Sometimes they burn through their stash too quickly, not even truly enjoying a large portion of it, and wish they had conserved some for later. It is through these and similar lessons that we build the intuitive-eating skills that can serve us so well throughout our lives.

The alternative is to regulate children’s candy experience for them by forcing or coercing them to donate, trade, or throw out all or some of their candy, or by rationing the candy for them. Using external cues to regulate our eating may seem to work in the short term, but in the long run the approach almost always fails us. One particular patient comes to mind, a teenage girl who ignores her body’s hunger signals and eats according to the commands of an app. She tells me that she does not trust herself to listen to her body and that obeying the app is already “ingrained” in her. I think of the countless adults who sit across the table from me, fold their arms, lean back, and say, “Just tell me what to eat,” because for most of their lives they have been taught that they cannot trust themselves.

Well-intentioned parents want to help, but the assistance is often misplaced. Help your children to build their relationships with food by giving them the freedom to manage their Halloween candy themselves. Consider prompting your children to ask themselves how hungry they are and what do they really want before the eating begins, but not in a leading or coercive way. Give them the space to answer honestly and to follow up their candy experiences with more candid questions: “How full am I?” “How am I feeling now?” “How did I enjoy it?” and “What, if anything, would I do differently next time I have candy?” Give them the freedom to make mistakes and learn through experience, for it is partly through these lessons that we build healthy relationships with food.

 

She Said

The other day, Jonah told me about a local news story he had seen about a bunch of people who are now going to put signs on their front doors proclaiming that they are a “candy-free” house and that, as such, they will not be handing out any candy on Halloween this year. Instead, these individuals will be handing out small toys to the youngsters who come trick-or-treating to their door. Of course, the intention of these individuals is to not promote the “obesity epidemic” by handing out sugary treats to little ones.

The first thing that came to my mind about Halloween candy and kids was, “What would Ellyn Satter say?” Ellyn is a registered dietitian and eating specialist focusing primarily on children. She has written a number of pivotal books about how to feed children and how to prevent and/or help rectify problematic eating early on to promote a healthy relationship with food in years to come.

As luck would have it, Ellyn wrote an article in 2008 about the topic of Halloween candy and kids. In her opinion, she believes that Halloween candy should be treated the same way other sweets are treated and that the child needs to learn how to manage his sweets and how to “keep sweets in proportion to the other food he eats.” She cites a 2003 research study that found that girls that were “treat-deprived” (i.e., were restricted by their mothers in particular around treats and sweets) were more likely to overeat forbidden foods even if they weren’t hungry. Conversely, the study found that girls that were allowed treats on a regular basis ate them moderately and sometimes not at all.

Given the above study, Ellyn’s advice is to use Halloween candy as a “learning opportunity,” in which the child should work toward being able to manage his or her candy stash with minimal interference by the parent. What does that look like? Well, she would suggest that upon returning from trick-or-treating, the parent should let the child “lay out his booty” of Halloween candy, sort it out, and “eat as much of it as he wants.” After letting the child do this on the evening of Halloween and the next day, the child should put away the rest of the candy, and it will then be “relegated to meal- and snack-time: a couple of small pieces at meals for dessert and as much as he wants for snack time.” She goes on to say that “if [the child] can follow the rules, he gets to keep control of the stash. Otherwise [the parent does], on the assumption that as soon as the child can manage it, he gets to keep it.” Finally, she recommends offering milk with the candy to make sure the child is getting some good nutrition.

Now, when I first read the above, I found my inner skeptic coming up front and center. How could one possibly trust that his or her child could regulate his or her sweets intake? Isn’t that the parent’s job? Otherwise, wouldn’t we have a bunch of little kids gorging themselves on any sweets they could get their hands on? What’s next? Letting kids start drinking at a young age to help them learn to do so moderately as adults? It all sounded a bit too much to me.

But the more I thought about it, the more it made sense. By taking the taboo off sweets and treats, kids will be less likely to overdo it when they are faced with them. I have a colleague who regularly has a rotation of sweet treats and salty snacks in her house and does not limit her kids around this. What ends up happening, she says, is that her kids don’t see these foods as “off-limits” and therefore not so tempting. They know that if they want these foods, they can have them, but since they are always available, the forbiddenness is no longer an issue, and they eat them in moderation or sometimes not at all.

So what’s the take-home message from the above? Restricting sweets and treats can lead kids (and adults) to view these foods as “forbidden” and then when faced with them, they will find themselves overdoing it on these foods even if they aren’t hungry or in the mood for them. By incorporating these types of foods into one’s meals and snacks on a regular basis, they become less charged, and the individual will view them simply as part of their diet, not as forbidden fruit.

HAES® and Eating Disorder Workshops

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Geographical fortune afforded me opportunities to recently attend two fantastic workshops right in my backyard: the Association for Size Diversity and Health’s (ASDAH) half-day workshop on Health at Every Size® (HAES) at the Multi-Service Eating Disorders Association, and the Hynes Recovery Service’s symposium on eating disorders in adolescent and young adult patients.

These conferences offered me chances to meet and learn from some brilliant colleagues, including, but not limited to, Ellen Glovsky, Lisa Du Breuil, Marsha Hudnall, Dawn Hynes, and Kim Dennis, some of whom I have known for years and others with whom I have been connected virtually but had never before met in person.

Dr. Glovsky’s talk, in particular, was terrific. They always are. She and I first met in 2007 when she gave a talk at the Beth Israel Deaconess Medical Center, where I was a dietetic intern. As soon as she finished speaking that day, I went up to the front of the room and introduced myself. We have stayed in touch ever since.

For lack of a better term, Dr. Glovsky just gets it. Having been a dietitian for approximately 40 years, she has evolved her counseling approach away from a classical directive style to the more effective motivational interviewing model that Joanne and I learned from her and use at our practice. Although Dr. Glovsky probably does not realize it, nobody has been a greater influence on my career than her.

Over the course of these two workshops, Dr. Glovsky and the other speakers shared many interesting points and anecdotes. The nuggets that really struck me are below.

  • Research indicates that 95% of people who intentionally lose weight regain the weight within five years. Of those 95%, 60% of them will end up heavier than they were at baseline. Said differently, if 100 people attempt to lose weight, five of them will keep it off, 38 will return to baseline, and 57 will end up heavier than when they started.
  • Because outcomes are only somewhat in our control, our goals are better constructed around performance and behaviors, not outcomes. For example, instead of saying we are going to lower our cholesterol by a certain number of points, we are better off setting goals to perform certain behaviors that may lead to lowered cholesterol with the understanding that some influential factors, such as genetics, are out of our hands.
  • Parents and doctors often miss the signs of eating disorders or incorrectly explain away said signs with other conclusions. Joanne asked one of the speakers how much of a dip in the growth charts should be considered a red flag. The speaker said a drop of five (for example, a patient’s body-mass-index-for-age drops from the 50th to the 45th percentile) or more indicates that something serious, such as an eating disorder, is likely at play. That reminded me of a patient’s mother who literally laughed in my face and never brought her daughter back to see me when I expressed concern that her daughter might be suffering from a yet-to-be-diagnosed eating disorder. In addition to the other reasons for concern that I saw, over the course of the last eight months her daughter’s body-mass-index-for-age had dropped by almost 20.
  • People suffering from an eating disorder or disordered eating frequently use the elimination of certain foods (“carbs,” dairy, gluten, animal products, etc.) as a means to restrict under the guise that the choice is supposedly about health, an allergy/sensitivity, or ethics.
  • A lawyer I spoke with between sessions told me she is working on using occupational safety laws to implement regulations for models in the fashion industry. According to her, the World Health Organization defines starvation as having a body mass index below 16.0 kg/m2, while the average runway model has a body mass index of 14.0 kg/m2.
  • Websites and social media groups that encourage eating disorders and offer tips to further their destructive behaviors are prevalent and easy to find. After a quick Google search that I did myself, I was shocked and saddened by what I saw in just the first few seconds. As one of the speakers explained, individuals with these conditions often seek out like-minded people online and isolate themselves from others. Pretty soon, these online communities become their entire world.
  • For some people, the term “fat” is an insult loaded with unfair and inaccurate stereotypes. For others, the word is nothing more than a neutral adjective describing body shape or size. Practitioners need to pay close attention to the language that our patients use and the intended meanings behind their words.
  • Every once in a while, I get someone who erroneously believes that HAES is just an excuse that larger people use to justify their size. As I looked around the room at the ASDAH event, I could not help but wish that those same people were there with me to share what I was seeing: People of all sorts of shapes and sizes were there, including many slender folks.