Author Archives: Jonah Soolman

Obesity Cuts Life Expectancy, Santa Is Responsible for Your Christmas Presents, and Other Misleading Statements

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My interest in writing a blog right now is pretty much nil, but I cannot let today’s misleading boston.com article entitled “Obesity Cuts Life Expectancy by Up to 14 Years, Study Shows” go by without reacting, for I know the damage that pieces like this do to people, including some of my patients.

Long story short: The researchers who authored the primary source article did not adequately control for behaviors. They screened out potential participants who had ever smoked and/or had a history of certain diseases, but the lifestyle behavior information they collected from participants was limited to alcohol use and physical activity level. Researchers collected no information about other lifestyle factors, like stress management and eating and sleeping habits, all of which can impact health. The behavioral data they did collect was self reported, which introduces all sorts of error. Other research has shown that when behaviors are controlled for, body weight does not seem to matter, but the study design that these authors used prohibited any opportunity from being able to confirm or refute those findings.

The boston.com piece discusses a second article as well that examined the relationship between obesity and exercise. In reference to this latter article, the boston.com piece’s subheading concludes with, “And it’s under-exercise, not overeating, that’s causing America’s [obesity] epidemic.” That eye-catching text will certainly garner many clicks, which is unfortunate because it is not true. The actual research piece reads, “The research highlights the correlation between obesity and sedentary lifestyles, but because it is an observational study, it does not address the possible causal link between inactivity and weight gain.”

I cannot stress it enough: Correlation is not causation. They are entirely different. I know, I know, we each know somebody who has put on weight after they stopped working out. Sure, that does happen sometimes, but on the macroscopic level that is the population, the picture is much more complex than that with many other factors in play.

The boston.com article’s final paragraph begins with, “Losing weight is proven to significantly reverse the health effects of obesity.” Wrong. When we adapt healthier lifestyle behaviors, our body weight might change as well, but if we credit the weight change instead of the behavior change then we have it backwards.

The harm in all of this is that it reinforces a weight-centered model of eating and physical activity that ultimately fails nearly everybody who uses it. If we take a weight-centered approach and do not maintain the weight we want, we risk losing motivation and reverting to old behaviors because the goal was unattainable.

There is a better way. In the health-centered model that we advocate, the behaviors in and of themselves matter independent of weight. Whether weight goes up, down, or stays the same is irrelevant because the behaviors themselves are what count. Better-designed research seems to support this model: When we control for behaviors, health and weight look to be independent.

Day 91: Progress (or Lack Thereof)

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Today was supposed to be my day. Circled on my calendar back in March, today was my three-month CT scan and appointment with my surgeon. Although full recovery from a surgery of this magnitude takes right around a year, three months is considered enough time for sufficient healing to take place that allows for a return to normal activities. My expectation was that I would come home from the appointment and go right out for a run, my first in nine months.

As it turns out, I will not be running anytime soon. The surgeon used bone grafts to build two columns in my lower back. The CT scan showed that the column on the right is healing as expected, while the column on the left is far behind schedule. The chunks of bone that he implanted on the left are still sitting there independently with only minimal growth around them.

The surgeon said this is highly unusual. Typically, people either heal well bilaterally, or they heal poorly bilaterally, but two different progressions simultaneously is rare. He has no explanation as to what happened. He tells me that on paper I am the ideal candidate to heal well: young, active, non-smoker, healthy eating habits, etc. “On paper,” therefore, seems to be the key term.

Instead of today being my last appointment with him, now I have plans to see him again in mid-August, at which time I will undergo more tests to check how the bone is healing. Perhaps the fusions will progress between now and then, or perhaps they will not.

In the meantime, I am feeling very discouraged and disappointed. There will be no bike rides this summer. My planned return to competitive running on the one-year anniversary of my last race is out the window. So much for playing ping pong with my nephews when they visit over Independence Day weekend. I will not be able to help pack, unpack, and set up our first house when Joanne and I move later this summer. When I pan across the horizon of my life, tennis is nowhere to be seen.

Instead, I have two months ahead of more of the same. Three months ago, I thought June 18th would never come. In reality, the time passed just as slowly as I anticipated it would. To think I was done and then find out I have to do it almost all over again, but with more uncertainty and less optimism this time, is quite disheartening.

The other day, a new patient came to me frustrated that his efforts to lose weight have gone nowhere. When I suggested that we try a different approach by focusing on making healthy choices, learning to love and accept himself regardless of his size, and letting his weight settle wherever it naturally belongs, well, he did not want to hear that one bit.

He looked down at my lean frame and explained to me that I do not know what it is like to be judged on appearance, that I do not know what it is like to feel uncomfortable in my own body, that I do not know how frustrating it is for my body to not respond the way I would like despite my best efforts, and that I do understand the apparent unfairness of seeing somebody with an attribute or an ability that I covet, but cannot attain, for myself. Yeah, clearly I cannot relate to any of those themes at all.

Everybody is dealing with something, and while the particulars are unique to each person, common ground exists underneath. No matter what our goals are, if we do the best we can to achieve them and we still fall short, then by definition there is nothing more for us to do except adapt and find a new way to thrive. When I wrote, “In this kind of defeat, you learn that there are incidents in life that are not up to us. We are only somewhat in control of our own destiny, and we have to roll with events and outcomes that do not go our way,” I feared that perhaps I was foreshadowing my own outcome.

Maybe that will prove to indeed be the case. However, I am not going to use that as an excuse to keep from doing everything I can, while still maintaining perspective, to meet my goals. Today sucked, but my bitching is over. It’s time to get back to work.

No Such Thing as Perfect

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The following piece was written by one of our patients, KC, a 32-year-old female from Wellesley.

Growing up as an athlete encouraged me to develop a commitment and eventually a passion for health and fitness. Over a year ago, that commitment turned into an unhealthy obsession. I lost the balance I once had and quite honestly it happened without me even realizing it. It took control of my life and isolated me from my friends and family and ultimately, it led me down a path of sadness and despair. This is my story of how strict discipline, unwavering dedication and the pursuit of perfection turned my otherwise healthy lifestyle into a battle with Orthorexia and exercise obsession.

I always looked to exercise for stress relief and an outlet when life became challenging and quite honestly, I still do. It was the one thing I could rely on. I felt a sense of calm when I planned strict workouts and meal plans. Sticking to them built my confidence, but failing to do so broke me down. I had to be perfect in order to achieve my goals of being fit. This discipline isolated me, but also made me feel better than everyone else. The more perfect I was, the more I separated myself from the average person. I looked down on everyone that didn’t share my passion for health and fitness.

I eventually developed such strict, unattainable rules failure was the only outcome. Each day I had to eat more cleanly and train harder than the day before. Even if I did achieve this for a period of time, I wasn’t capable of maintaining this intensity and in my mind the only solution was to be more strict. I started a food journal, something I have done my entire life off and on. In order to control my “bad” habits and cravings I felt it was necessary, although it only set me up for more potential for failure. The dieting world promotes food journals as a way to control calorie intake and unnecessary binges. I believe it can be a positive tool for those trying to develop better eating behaviors. However, this only contributed to my perfectionism, obsession and unrealistic ideals for myself. The more I recorded, the more I restricted.

At the time, I was experiencing discomfort with my stomach, which I blamed on my eating habits. It caused sleepless nights and uncomfortable days so I developed another rule, no eating past 8pm. This eventually ruined my social life. I had to rush home after work to eat dinner and declined all invitations to go out. For a while, I was convinced that it made me feel better physically, but the guilt I felt from avoiding parties, friends and anything social greatly affected my self-esteem. I justified it by telling myself I had to stick to the rules and staying out too late would no doubt ruin my workout the next day. The irony was despite following my rules and avoiding social settings my workouts weren’t always perfect. This only added to the growing feeling of failure and ultimately I wasn’t happy.

At this point, my dedication should have given me positive self-reinforcement and contentment. I was nowhere near content. I was exhausted all the time, injuries were creeping up, and I wasn’t enjoying myself at the gym like I once was. In addition, as hard as I was working out, I felt like my body looked awful and therefore I needed to push myself harder. This vicious cycle continued for months. I couldn’t look in mirrors because I felt like I wasn’t getting the results I should be. I avoided anything social because I felt like I needed to reach that level of perfection in order to feel good enough in my clothes to go out and be around people. I was stuck in a rut of failure, frustration and disgust. I found myself constantly comparing myself to others. I felt if I could maintain healthier habits than the people around me, I was ultimately more dedicated to fitness than anyone else.

One temptation that I always tried to control was my love for sweets. I figured if I eliminated eating them altogether I could get even better results at the gym. In reality, I didn’t get better results, I just deprived myself of something I enjoyed for the sake of achieving that perfect image. The interesting thing was I never defined what perfect was. I was constantly chasing something that wasn’t realistic. I just figured I would know what perfect felt like when I got there, but of course I only found sadness and disappointment.

My fitness became my identity. I figured it was the only real reason people liked me. They knew me as the fit girl. If I did overeat and not train hard enough, I wouldn’t be living up to that fit girl image. When I did overeat the punishment I put myself through at the gym was extreme in addition to depriving myself further of the nutrients to get rid of the heavy bloated feeling as a result of the overeating. My meal planning became so structured, I completely lost touch with listening to my body and I didn’t trust my body to make the right decisions. I would force myself to eat things I didn’t even want because they were ‘healthy’ and in my mind would get me closer to my goals. I planned my meals a week in advance and I ate based on the clock, not how my body felt. I had to eat 5-6 meals a day to get all the nutrients in I needed whether I was hungry or not. I realize now, I never enjoyed what I ate or really tasted my food. It took all the pleasure out of eating.

Despite the fact that I was so sad, I was still able to fake a smile. Everyone in my life knows me as a happy person so I had to keep that up. I’ve had people say to me, “You are so happy all the time, I don’t know how you do it”. Honestly, at this point in my life, I didn’t either. I was able to be happy on the outside, but miserable on the inside living a life of solitude. I knew after months of feeling this way something had to change. It was wearing me down physically, emotionally and psychologically. Initially, I was fearful if I got help I would be told that my lifestyle was crazy and obsessive and would be encouraged to drastically reduce my exercise intensity. Reluctantly, I went to therapy.

Talking about my fears and habits helped, but I didn’t change. I realized a lot of our conversations focused on my nutrition, especially when I talked about my stomach pains. My therapist encouraged me to see a nutritionist. I willingly agreed to this because it was such a passion of mine and maybe this person would be able to finally help me reach my goals. I didn’t realize it at the time, but it ended up being a life changing decision that opened my eyes to a severe pattern of disordered eating. I had no clue how much food was controlling my life. My rules and relationship with food took priority over everything in my life. Until I started talking about my feelings toward food and the role they played in my life, I had no idea how much I was under its control.

I was encouraged to read a book called ‘Health Food Junkies’, a book that focused on the eating disorder Orthorexia Nervosa. It was absolutely eye opening. I identified with every story and every statement made about what I now realize to be an unhealthy relationship with food. This really started my journey to truly becoming healthy in my mind and body. I had to relearn how to listen to my body. I had no idea what I felt like eating because I lost touch completely with trusting what my body was telling me. I remember being in the grocery store without my list and recipes for the first time in months and I felt completely lost. Despite feeling lost, I did have a sense of excitement going to the grocery store and shopping based on what I wanted to eat not what I should eat. To relinquish my rules was terrifying and I was afraid to fully trust myself. I wanted to get better, but was fearful that it would have a negative impact on my body. If I sounded conflicted, I was.

I will never forget the session when I was encouraged to eat a cupcake for dinner. Restricting myself from all sweets made me crave them more. I was excited to have this freedom. Within that next day, I bought two huge cupcakes and ate them on the way home in the car for dinner. I was finding sprinkles in my seat for days after. It was the first time I listened to my body in months and it felt empowering. I knew this was the turning point in my recovery. Cupcakes for dinner blew my rules out of the water and it felt pretty awesome.

I started to really believe that listening to my body was the way to achieve the results I wanted all along. It was telling me exactly what it needed to keep me healthy. My body told me when to eat and what to eat. I also started listening when it told me to take a day off from the gym. My social life and relationship with family were becoming strong again. I felt truly happy. For the first time in a long time, I realized being real was a much more fulfilling lifestyle than being perfect. To this day, I carry these valuable lessons with me. I am still one hundred percent committed to my health and fitness. It will always be a passion of mine, but I allow myself the freedoms I never did before because to me this is what it truly means to be healthy.

Health-Focused Weight Management

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“So I was just reading the Huffington Post article that you guys posted on Facebook. Serious question, is it possible that the pride in your body movement has gone too far? I understand the evils of anorexia, bulimia, and other eating disorders, but being fat, especially as fat as the woman in that article, is bad, right? If I eat unhealthily and stop exercising, I gain weight (see, e.g., the 4 months after [my son] was born). So fat [name omitted] is more unhealthy than skinnier [name omitted] (to a degree, of course). And the people who I know that are overweight clearly have the worst eating habits and some of them have ended up with diabetes, high blood pressure, and cardiovascular problems.

“So why this big movement of pride in your body no matter how fat you are? I feel like it’s teaching a dangerous message. That lady in the bikini needs to lose weight by changing her diet and exercising more, doesn’t she? Being thinner will inevitably be better for her health and decrease the risk of her getting weight-related health problems. So why are we celebrating her being proud of how fat she is and then broadcasting to the world that she should be proud of her body no matter what?”

One of my best friends sent me the preceding email in response to me posting the Huffington Post article he mentioned on our Facebook page. We have been friends for decades and I know he asks these questions with honest, open-minded curiosity. Here are the points I wrote back to him.

1) Obesity is associated with health problems, but to my knowledge the legitimate research has never established a causal relationship despite attempts to do so. In fact, what the research has shown is that behaviors (smoking, physical activity, fruit and vegetable intake, proper sleep, limited alcohol consumption, etc.) are the real predictors of morbidity and mortality. When we control for these sorts of lifestyle choices, health outcomes are basically the same regardless of body weight.

2) Even if being obese was in and of itself a legitimate health problem, we really do not know how to help people lose weight and keep it off for the long run. The research shows that about 95% of the attempts people make to intentionally lose weight fail in the long run, and the majority of these people end up heavier in the end than they were at baseline. Weight regain can be due to behavior change, but it can occur even when the behaviors that yielded the weight loss are maintained. From an evolutionary perspective, consider that we are designed to keep on weight, not lose it, for the sake of survival. I have a patient who lost about 40 pounds, her motivation to keep it off is sky high, and she is very strict about maintaining the behaviors that got her weight down. Yet the weight is starting to creep back on slowly but surely. We can only do so much to fight biology.

3) When somebody tries to lose weight and it does not go as planned, the endeavor is not necessarily harmless. In other words, they do not automatically just return to baseline as if nothing happened. Weight cycling can cause everything from depression to metabolic issues like high blood pressure and high cholesterol. Given that 19 out of 20 weight-loss attempts fail, we need to really consider these risks.

4) The social stigma about being overweight pushes people into weight loss attempts, which we know are likely to fail them. We have a “war on obesity” in this country, which is ridiculous considering there are people everywhere making all sorts of behavior choices that could legitimately be considered unhealthy, but they do not face the same ridicule. Where is the outrage against people who do not get enough sleep? Why don’t we bitch about inadequate sleepers raising health care costs for the rest of us? Why don’t people who yawn in public seem to face the same bullying and looks of disgust that many obese people deal with on a regular basis? Our culture is so unaccepting of people who we deem overweight that we push them into weight-loss attempts that will likely leave them less healthy in the long run.

5) Because they are trying so hard to lose weight, Americans spend upwards of $60 billion annually on weight-loss programs and products. That’s insane. Imagine if we took those same resources and put them towards things that would actually help with health: cooking lessons, sports equipment, fruits and vegetables, walking shoes, gym memberships, comfortable mattresses, etc.

It is true that when somebody adapts unhealthy lifestyle choices, he or she might gain weight. If we have a baby and no longer have time for physical activity or proper sleep, for example, our weight might increase. The weight gain itself is just a symptom of the problem though, as opposed to actually being the problem. The real issues at hand are the lifestyle changes that happened to result in weight gain.

At the same time, we cannot conclude that somebody who is heavier automatically has an unhealthy lifestyle. Too many factors, including genetics, are in play. If we look at a heavier person and make any assumptions about how he or she leads his or her life, we are showing a prejudice that is as abhorrent and as any other stereotype.

The approach I take with my patients is to focus on behaviors, establish healthy lifestyle choices, and let the weight settle wherever it naturally belongs. Because our weight may or may not end up where we, our moms, our partners, society as a whole, etc. would like it to be, I encourage people to love and accept themselves no matter what they look like or weigh. That is why the Huffington Post piece and similar posts that confront weight stigma and call for size and weight acceptance are so important.

Day 67: Marathon

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Boston Marathon starting line, Hopkinton

Selfie of my feet at the Boston Marathon starting line, Hopkinton

A little over a month ago, my surgeon gave me permission to slowly ride the recumbent exercise bike and perform basic upper-body resistance movements with light hand-held weights. The doctor’s clearance for new exercises is mandatory, but so is my body giving me positive feedback in response to said activities. Unfortunately, I only had one of the two. After a few times of giving these exercises a try, my back pain seemed to worsen, so I put the bike and weights on hold and returned to exclusively walking.

Because several walks in the range of 12 to 16 miles felt fine and left me feeling like I could have done more, I decided to go a bit farther today. Early this morning, my back brace and I took the first commuter rail train of the day out to Ashland, where I met the taxi that then dropped me off in Hopkinton, right at the starting line of the Boston Marathon. 7:28 later, I walked across the finish line in Copley Square.

Boston Marathon finish line, Copley Square

Boston Marathon finish line, Copley Square (Photo courtesy of a tourist who was nice enough to take my picture after I told her I had just finished walking the entire route)

He Said, She Said: Lessons from Mom

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He Said

1) Food Can, and Should, Be Fun

I often went grocery shopping with my mom, and I helped her make meals, too. Because I enjoyed baking, she let me experiment with various recipes, including many of which I made up on my own. Some turned out well, others not so well. Regardless of the results though, by involving me in the food selection and preparation process, my mom taught me to have an appreciation for food that I would not have developed if food just suddenly appeared on my dinner plate. I learned that food can, and should, be fun.

2) Listen to Hunger/Fullness Cues

Perhaps in part because they lived through the Great Depression, my grandparents’ generation seemed to emphasize finishing everything on the plate. “There are people starving in China,” I would hear; as if by overeating, I would somehow lend a hand to somebody in need on the other side of the globe. My mom stood up to this misguided notion and taught me to listen to and honor my hunger and fullness cues. Forcing food down past the point of comfortable fullness helps nobody. Uneaten food can be packed up and saved for later. If we must throw it out, at least we learn a lesson to take or make less next time.

3) Where Food Comes From Matters

My brother and I were raised mostly eating organic foods, especially fruits and vegetables. The potential advantages of organic versus conventional foods are debatable, but I learned several lessons from my mom’s emphasis on eating organic: A food’s identity does not automatically indicate its quality; where it comes from and how it is grown/produced/raised matter.

4) Balance Is Key

When parents restrict their children from eating certain foods, the resulting irony is that the children often end up overeating on the forbidden foods as soon as they get access to them. In recognition of this reality, my mom instituted a “Sweet of the Day” policy, whereby my brother and I got to have a small treat each day. We enjoyed our favorites in quantities that did not ruin our health, and we learned not to see any foods as “bad.” In short, this policy was my initial exposure to the concept of nutritional balance.

5) Always More to Learn

Even though she has no formal study in the field, and her employment has nothing to do with the subject, my mom has always taken an interest in it, reading articles, newsletters, and magazines. Research is constantly yielding new insights into nutrition and health. Not only do I have to stay on top of new developments in the field, but I have to be open-minded enough to consider new information and opinions that challenge the status quo.

 

She Said

My mom is one of the most amazing women I know, and she inspires me in many different ways. One of the areas she has the most expertise in is cooking. Just looking at her kitchen, one can see all of the evidence of an experienced chef – tons of dog-eared and worn cookbooks, various cooking gadgets, and binders filled with old family recipes passed down from her mother (and her mother’s mother). Along the way, I have learned a number of nutrition lessons from her, and here are just a few of them.

1) Food is more than just fuel.

In nutrition school, a lot of the focus is on the science of nutrition – chemistry, physiology, nutrient metabolism, etc. But there is so much more to nutrition than just calories in/calories out. Food is family, love and connection. Some of my earliest memories are of my mom cooking and baking, so calm and happy in her kitchen. Of course, every holiday has its traditional meals – roasted turkey and Saltine stuffing on Thanksgiving, brisket and matzo ball soup on Passover, and chocolate brownies for dessert on July 4th. Aside from the holidays, though, my mom’s food can elicit such strong feelings of warmth and comfort. Her oxtail soup is a hearty, thick stew, perfect for cold winter nights. Her sweet and sour tomato cabbage soup is perfectly balanced and is the perfect meal with a piece of crusty French bread. More than anything, her food nourished the soul, and, in turn, inspired me to learn more about the wonderful world of nutrition.

2) When cooking or baking, always use real, fresh ingredients.

Whether the trend was low-fat, low-carb or just plain low-calorie, when it came to cooking and baking, my mom rarely ever made ingredient substitutions in her recipes. Butter, cream, and sugar were regularly used in her kitchen to concoct delicious desserts. Likewise, if the recipe called for bone-in, skin-on chicken, then boneless, skinless chicken breasts wouldn’t cut it. Foods that are made with real, whole, unadulterated ingredients are not only so much better tasting than the diet-y, low calorie stuff, they are more satisfying and satiating. Think about this – on a hot summer’s day, when you are craving an ice cream cone, will fat-free frozen yogurt really satisfy you? In all likelihood, you will eat the frozen yogurt and then, still feeling deprived, munch on other stuff afterwards. Better off sticking with the real treat; it will take less of it to satisfy you, and you won’t feel deprived.

3) You can make your own food rules.

While most of the time we had traditional meals in our household, every once in a blue moon, we would do something out of the ordinary. One time, my mom and I had ice cream for dinner! Obviously, this is not something I would recommend anyone do on a regular basis, but once in a while won’t kill you. We would also occasionally do “breakfast for dinner,” which meant omelets, cereal or bagels for dinner. At the end of the day, you don’t need to follow the food pyramid guidelines (or MyPlate) to be a healthy eater. Mixing it up can be fun and can get you out of a food rut, too.

4) Food tastes so much better when you let yourself enjoy it.

It is not unusual to hear my mom voice her love of food. Dinnertime was (and is) often filled with “mmmm’s” and “yummm’s” and other sounds of pleasure. While this habit of my mom’s has embarrassed me on occasion (mostly during my teenage years), more often than not, I find myself doing the very same thing! It is okay to enjoy your food! Let me rephrase that: The enjoyment of one’s food is a wonderful part of life. Not only is delighting in one’s food a wonderful part of life, there are studies that show that nutrients are absorbed better when the eater is enjoying his or her meal. So go ahead, savor, enjoy and delight in your food – it’s human nature!

5) There are few things more satisfying than planting, harvesting and eating veggies from your own garden.

I have many fond memories of my mom tending to her vegetable and herb gardens. She would grow everything, from tomatoes and zucchini to snap peas and basil. There is a certain joy in watching these plants grow from seedlings to ready for picking. And there is nothing better than crunching into a snap pea straight off the vine. Oftentimes, zucchini in my mom’s garden would be so numerous that it would be difficult to figure out what to do with all of it! Aside from a tasty side veggie, my mom incorporated this bounty into zucchini bisque and zucchini bread, which to this day are some of my favorites. Unfortunately, the next-door neighbor’s trees have grown so tall that my mom’s garden can’t grow anymore. But she still has her herbs, and they show up in many of her recipes.

I owe a lot to my mom in regard to my appreciation and interest in food. She taught me to be adventurous and try new things. She showed me how nourishing a well-prepared meal can be. And most of all, she taught me that food is so much more than just food.

Why Your Self-Diagnosis of a Gluten Sensitivity Is Probably Wrong

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I have a fear of needles. Before my surgery, I went for an MRI and the technician told me she would be using contrast dye. Great. Because even the sight of needles freaks me out, I looked away as she inserted the IV. Although I could feel the IV in my arm the entire time I was in the tube, I managed to never once glance at it, as I knew that would send me into a panic.

As soon as the scan ended, I anxiously asked the technician to please hurry and take out the IV. She looked at me confused, then gently explained that I did not have an IV. She had given me a shot, not an IV, and the needle was long gone before the test even started. The sensation of an IV in my arm during the MRI was concocted by my own imagination based on my belief that such an IV existed.

Our susceptibility to the power of suggestion is not a source of embarrassment or shame. Although I am no expert in the field of psychology, my life experience suggests to me that virtually all (if not literally all) of us experience placebo/nocebo effects in one way or another. Seems to me it is just part of what makes us human.

This element of our nature is a major confounding factor with elimination diets and self-diagnoses of food sensitivities. Your perceived gluten sensitivity is probably off base, just like the sensation I felt in my arm from a non-existent IV, because of your expectations.

Before I continue, I want to interject that despite the Business Insider article that came out recently entitled “Researchers Who Provided Key Evidence for Gluten Sensitivity Have Now Thoroughly Shown That It Doesn’t Exist,” gluten sensitivities do seem to exist. One of our colleagues, for example, was having such terrible migraines that her medical team wondered if she might have a brain tumor, but she came to find out that a sensitivity to gluten was causing the attacks. Since going gluten-free seven years ago, her migraines have completely disappeared.

So while the article’s title is an overstatement, the research study behind it hints at an important point: Gluten sensitivities are much more rare than today’s culture would lead us to believe.

Patients of mine have blamed their symptoms on gluten. After they made an effort to eliminate gluten, their symptoms resolved. Here’s the thing though: They were still eating gluten; they just did not realize it. For example, some patients correctly knew that wheat contains gluten, yet they continued to consume certain wheat-free grains and products not realizing they still contained gluten.

A very common and specific example is Ezekiel bread. Because of the bread’s marketing, some consumers associate the bread with health. Because of misinformation (According to research reported in the October 2013 issue of the Tufts Health and Nutrition Newsletter, 35% of people who buy gluten-free products do so because they believe them to be “generally healthier” than their gluten-containing counterparts, while 27% believe going gluten-free will help them lose weight. Both of these generalizations are incorrect.), they also associate health with gluten-free. Therefore, by the transitive property, they assume Ezekiel bread is gluten-free. But it isn’t; Ezekiel bread is loaded with gluten. The first ingredient is wheat, the second ingredient is barley, and the manufacturer even adds extra gluten, presumably for a protein boost or for texture reasons.

It seems, therefore, that these patients felt better because they expected to feel better or for some other reason, but not because of gluten itself.

If you are concerned that gluten might be problematic for you, make an appointment to see your doctor to discuss your concerns and legitimate methods of testing. In the meantime, continue consuming gluten, as eliminating gluten prematurely can make diagnosing a real gluten issue more difficult.

If it turns out your self-diagnosis was wrong, don’t feel bad. Remember, we all imagine that proverbial needle sometimes.

Beef and Broccoli

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As a dietitian, I am neither for nor against vegetarian and vegan lifestyles. I have seen too many people take different paths to health to pretend that one road is right for everybody. I am for whatever works for the patient sitting with me at any given time. What I am against though are misleading oversimplifications, such as a meme I saw that posed the question, “Do you really need to eat meat to get protein?” followed by single bites of beef and broccoli and the accompanying statistics that beef contains 6.4 grams of protein per 100 calories in comparison to broccoli, which contains 11.1 grams of protein per 100 calories.

Let’s look closer at the numbers. According to the USDA National Nutrient Database, 100 calories worth of raw broccoli contains 8.31 grams of protein (or 6.83 grams if cooked), not the 11.1 grams reported in the above meme, but let us pretend that the protein content in the graphic is correct and go with it. Broccoli is so low in caloric density that it would take eating 3.25 cups of raw broccoli in order to ingest 100 calories of the vegetable. That means that a 150-pound individual, whose protein needs are likely at least 68 grams per day, would need to consume 20 cups or more of raw broccoli in a single day in order to meet his or her protein needs. Good luck.

In comparison, one would only have to consume 1.75 ounces of steak to reach 100 calories. According to the USDA Nutrient Database, that amount of steak would provide 13.66 grams of protein, not the 6.4 grams reported, although I can imagine that variables like the specific cut of beef and utilized preparation method are possible explanations for the two-fold discrepancy. Either way, the math shows that steak is a much more concentrated source of protein than is broccoli.

By showing one bite each of steak and broccoli side by side, the picture leads one to assume that the protein contents being compared are found in those two forkfuls of food. Think of how fast we breeze through our social media feeds. Honestly, how many people do you think pay attention long enough to disconnect the text from the graphics and realize that grams per calorie are being compared, not grams per bite? Conversely, how many viewers do you think take a quick glance and then move on, left only with the false impression that broccoli is a source of concentrated protein?

Changing the illustration to one that shows a piece of steak approximately half the size of a deck of cards next to a pile of raw broccoli almost the size of two Ben & Jerry’s pints would better represent reality, but that would not look so good for the vegan argument. I think we can safely assume that the creators of the meme realized this, hence their decision to instead opt for the misleading fork graphics.

The issue at hand is not one of animal versus vegetable. The point is that in our culture of fast-paced memes, Tweets, headlines, and soundbites, true meaning often gets skewed, either unintentionally or purposefully in order to fit an agenda. Despite the inconvenience of vigilance, taking the time to really consider and understand a post before clicking the share button can spare ourselves and our connections a great deal of confusion and misunderstanding.

Looking the Part

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Wow, I am hard pressed to remember an instance when something I read made me as angry as Juliann Schaeffer’s article in Today’s Dietitian entitled “Dietitians and Their Weight Struggles.”

In summary, the article contains quotes from dietitians who offer their opinions as to whether or not a dietitian’s weight and appearance should matter. Although the piece improves at the end when some sanity and rationality is injected into it, the beginning quotes from one of my fellow dietitians are so shamefully off base that I feel deeply embarrassed to be associated with her.

“If someone has a weight issue, then in my opinion, they should choose a specialty that does not conflict with being overweight.”

“If you can’t make it work for you, how can you make the case for someone else?”

“. . . the reality is that health care is a business, and people do judge you by appearance. Is it right or wrong? That doesn’t make a difference. It’s a business, and it is what it is whether we like it or not.”

“I wouldn’t think much of advice from a cardiologist if I knew he had had a heart attack.”

So wait, are we dietitians supposed to list our BMIs on our resumes and websites now, or how does this work?

It is one thing for some personal trainers, chiropractors, life coaches, “nutritionists,” therapists, doctors, and other dietitian wannabes to go outside the scope of their expertise and give harmful dietary guidance, but when an actual dietitian represents the profession the way she has there is just no excuse for it. This is our wheelhouse. We should be better than that.

When I was an intern, I had a rotation in a bariatric surgery clinic where two dietitians worked. One was heavier, one was leaner. Some patients did not want to work with the heavier one because they questioned, “Look how heavy she is; how can she possibly help me?” Yet other patients did not want to work with the leaner dietitian because they worried, “Look how skinny she is; how can she possibly relate to what it is like to be fat?”

Last year, a new patient told me she almost cancelled her appointment because she was intimidated by what a “great athlete” I was. Just a few months ago, another new patient came to me all impressed that I had “beaten cancer.” Well, no, I did no such thing. She had misunderstood my online autobiography. When I told her that, she deflated like a balloon.

Let’s get real for a moment. The whole notion that a practitioner has to look or behave a certain way in order to help patients is incorrect. Out of all the questions I asked the surgeons I met with before my most recent back surgery, I never thought to ask who among them has back problems. But I should have because if a surgeon has back problems then it is logical to conclude he or she cannot help me with my issues, right? Or wait, I want a surgeon with back problems because he or she can relate to my experience, is that how it goes?

How about just finding the surgeon whose approach, experience, and demeanor made me feel most comfortable and confident? I know, crazy me and my outlandish notions.

During my first year as a personal trainer, few members were interested in my services. Although I had good relationships with many of them and they routinely asked me questions about exercise, few were willing to cross the line of actually hiring me. However, after I took two months off to ride my bike across the country, suddenly members were booking sessions with me left and right and my boss began to refer new clients my way, too. Other trainers treated me and my opinions with more respect. The gym even gave me a raise without me asking for it.

Come on.

Sure, more money and clients were great, but the driving force behind the upturn in business was so ridiculous that I felt insulted. It took riding my bicycle 4,000 miles, up and down mountain ranges, through all sorts of weather, for my expertise to be recognized and taken seriously? The ride did not make me a better trainer. If anything, I was a worse trainer after my trip because I was rusty from not having worked in two months. But hey, perception is all that matters to some people.

Right now, I have a patient who wants to be a CrossFit coach and feels she needs to lose 15-25 pounds in order to be taken seriously by potential clients. Sure, she has room for changes in her lifestyle, just like we all do, but she generally eats well and takes great care of herself. As disappointing as it is for her to hear, it seems her body just naturally belongs 15-25 pounds heavier than she would like it to be. Do I push her further down the path she feels obligated to follow, risking perhaps disordered eating or an eating disorder, as she sacrifices health for a number and a look, or do I guide her towards the reality that she can be a great trainer no matter her weight and appearance?

Due to my surgery, it has been seven weeks since I lifted weights and did any physical activity in earnest. Muscle atrophy is setting in. My shoulders and chest are smaller. My six pack is gone.

Am I a worse dietitian now than I was two months ago?

What if you did not know that major surgery had affected my fitness and you came in here and saw a scrawny dietitian without any context? Would you have less confidence in me than if you knew about my operation?

What if I had not undergone surgery and I just decided to take two months off from working out?

What if I had a healthy relationship with both physical activity and food, but my body just happened to be thinner, less muscular, or heavier than society feels its dietitians should look? Would you go elsewhere?

I have blogged about my athletic accomplishments, such as my mountain running, on a small handful of occasions because it can enhance patient care for them to understand that I am a human being with a life outside of this office and I face challenges just like everybody else. Perhaps patients garner some inspiration from those postings, but if anybody reads one and then comes to see me with the mindset, “Jonah is thin and Jonah is an athlete; therefore, he can help me,” God, that would just make me want to take all of the posts down. I just cannot be part of that act.

The purpose of self-disclosure is to enhance patient care, not to serve as an advertisement, not to capitalize on misconstrued ideas, and certainly not for a practitioner to defend or justify his or her behaviors or body shape.

I disagree with the notion that health care is a business. The first priority should be patient care, not money. If the dietitian I quoted earlier had her priorities in order, she would be helping to reeducate her patients and change a culture of misunderstanding rather than playing into it for profit. Giving people what they want and expect for the sake of financial reward does not justify providing poor care and perpetuating a myth.

Or maybe I should just play along and take up steroids, lest patients go elsewhere because I no longer look the part, right?

Come on.

He Said, She Said: Meal Plans

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Creating meal plans based on calorie needs has been a staple of nutrition counseling for years. Is it time to say good-bye?

He Said

“The first session is about food. Every session after that is about why they [the patient] are not doing what I told them to do.”

That is how a seasoned colleague explained her work as a nutrition counselor to me when I was just starting out as a dietitian. With all due respect, the quote illustrates nutrition counseling gone awry, the result of an outdated, archaic, and ineffective approach that puts too much emphasis on information and too little on individuality and motivation.

A popular tool in dysfunctional nutrition counseling is the meal plan. While meal plans can take on different forms, the kind that I am referring to is based on an estimation of the patient’s calorie needs; those calories are then broken down into numbers of servings that said patient should consume from various food groups over the course of the day.

In theory, meal plans sound like a useful tool. From a dietitian’s standpoint, meal plans are easy to create, they give patients flexibility, and they put the responsibility for execution entirely on the patient’s shoulders. From a patient’s perspective, meal plans give a welcome sense of certainty and control, thereby temporarily relieving feelings of confusion and powerlessness. Just follow the meal plan and everything will be okay, right?

Unfortunately, the problems with these meal plans are extensive:

  • Estimates of the patient’s nutritional needs are not tremendously accurate. The most accurate means of measuring one’s resting metabolic rate is through direct calorimetry, which involves spending time in a chamber that measures the heat he or she generates. To my knowledge, direct calorimetry never happens outside of a research setting.  Even direct calorimetry has its problems, and every other method available has larger sources of error. Practitioners like us use algorithms that estimate calorie needs based on height, weight, age, gender, and similar data. Attempts to quantify calories expended through physical activity introduce additional error. Calculations of one’s calorie needs are at best just rough ballpark estimates. Therefore, the whole foundation of the meal plan is shaky.
  • The reported calorie content of different foods can also be inaccurate. Whether due to faulty assumptions used in the calculations or labeling laws that allow for rounding off, what we believe to be the nutritional content of a given food is sometimes not quite true. Yet the numbers are taken too literally, and patients exhaust themselves with kitchen scales and measuring cups trying in vain to consume the exact number of prescribed calories, a goal that is virtually impossible to achieve.
  • The expectations put on meal plans are unrealistic. With genetics, environment, stress, and other variables heavily influencing health and weight outcomes, the notion that a meal plan can guarantee virtually any measure of success is nonsense and misleads patients.
  • Meal plans fuel the inaccurate “good food, bad food” dichotomy. Foods present on the plan are seen as “good,” while those that are absent are considered “bad.” One meal plan form that I used to use omitted some fruits for no other reason than space did not allow for a complete list, yet countless patients expressed criticism and fear of the fruits that did not appear on the plan.
  • Meal plans focus heavily on individual foods, but much of the foods we consume in real life are combined with other foods in unknown quantities. Even when we prepare foods at home, estimating, for example, the volume of beans in minestrone soup, or cheese on pizza, or oil used in a stir-fry with any degree of accuracy is a time-consuming and tedious challenge. When eating in a restaurant or buying prepared foods, forget it; there is virtually, or in many cases literally, no way to know. The meal plan paradigm of tracking portion sizes fails when portion sizes are uncertain.
  • Meal plans teach patients to follow external cues for their eating. This may work in the short term, but not in the long run. At best, relying on a meal plan delays the development of mindful-eating skills. If long-term change is to occur, it is virtually inevitable that one must learn to eat in response to internal cues.

Following in the footsteps of my more experienced colleagues, I put hundreds of patients on meal plans at the beginning of my career. Some of these patients saw short-term improvements in their health or weight, but I cannot recall even a single instance of a meal plan approach spawning long-term behavior change. When things inevitably fell apart, patients blamed themselves, but really the problem was the approach. For that reason, I recognized meal planning as the dated and ineffective technique that it is and almost entirely removed it from my counseling tool box.

The only exception is that I still use meal plans for some patients with eating disorders. Sometimes the stakes are so high that inadequate nutrition risks hospitalization or admission to an inpatient program, so in these cases I temporarily use meal plans in an effort to keep the patient safe. In the long run though, as the eating disorder is overcome, we leave the meal plan behind and work on mindful eating.

There are times I do devise lists of meal and snack ideas with my patients, but do not confuse these with the meal plans that I have discussed up to this point. Working together with my patients to devise individualized ideas for what they can eat in certain situations can be very helpful due to the customization and collaboration. The utility is quite different than just writing in some numbers on a meal plan sheet, handing it over to them, and then getting together next session to discuss why they are not following it.

 

She Said

To meal plan or not to meal plan, that is the question. A lot of people assume that since the majority of my patients are those with eating disorders, that I must use meal plans with all of my patients. This most definitely is not the case. When a patient first comes to see me, I spend the initial session (or two) learning about that patient: Why are they coming to see me? How have they been eating? At what point in their recovery are they? These are all questions that can help me decide whether a meal plan is indicated or not.

Meal plans, in my opinion, are training wheels for those struggling with feeding themselves adequately. Usually, if a patient has just left an inpatient or residential eating disorder treatment facility and is having a hard time eating all of her meals and snacks at home, I find that a meal plan can be very helpful to get her back on track. But, just like training wheels, the meal plan should not be permanent, and eventually the patient should be weaned off of it.

The ultimate goal that I want to help my patients achieve is the ability to engage in intuitive eating. In a nutshell, intuitive eating is eating when you are hungry, stopping eating when you are satiated, and eating what feels best to your body. This also means not eating according to external rules, but rather listening to your body and honoring its cues.

As I’ve mentioned before in other blogs, we are born with the innate ability to regulate our food intake. When a baby is hungry, she will cry until she is fed. When she is full, she will turn away from the offer of more food. Even toddlers still use internal cues to determine when and how much they want to eat. But, eventually, we begin to lose the ability to listen to our body’s cues when we start placing external regulations on our eating (e.g., eating according to a strict schedule, dieting, being a member of the clean plate club, etc.). This behavior causes us to lose touch with our body’s innate wisdom and can lead to disordered eating.

I rarely, if ever, use meal plans with my non-ED patients, although I’ve had many of them ask for one. I find that those patients who ask for meal plans are the ones that want to be told what, when and how much to eat and don’t trust themselves to feed themselves appropriately. They want to rely on external regulations around their eating, as they feel that if left to their own devices, they would devour an entire sheet cake in one sitting. In these instances, using a meal plan is not a good idea, as it just reaffirms in that patient’s mind that she is incapable of feeding herself solely by using her internal wisdom.

In sum, while I think meal plans can be a useful tool in ED recovery, they are not indicated in every instance. The ultimate goal is to relearn how to eat intuitively, and that means not relying on a meal plan, but instead listening to one’s gut.