Pinkalicious

Posted on November 29, 2023 by Jonah Soolman

Mondays are our kindergartener’s “media day,” which means she and her classmates visit her elementary school’s library and have an opportunity to borrow a book for the upcoming week. During one Monday afternoon walk home from school, she gave me a synopsis of the book she was taking home, something along the lines of, “She [the main character] eats a lot of pink foods and turns pink, then she eats more pink food and turns red, and then she eats green foods and her color turns back to normal.”

Uh-oh.

Right off the bat, I had a feeling where this was going. My intuition proved correct once I read the book myself. Pinkalicious is a funny and cute book, but it is problematic in certain ways. If your child is going to read it, an accompanying and clarifying conversation will be important in order to mitigate harm.

The story begins with the main character, a young girl named Pinkalicious, baking pink cupcakes on a rainy day. She disregards her parents’ commands and eats so many of them that she wakes up in the morning and discovers that she has turned pink. Her doctor diagnoses her with a case of “Pinkititis” and advises her, “For the next week, no more pink cupcakes, pink bubble gum, or pink cotton candy.” The doctor continues, “To return to normal, you must eat a steady diet of green food.” Immediately thereafter, the book reads, “(YUCK!)”

The accompanying illustration shows several pink foods crossed out, indicating that Pinkalicious is to abstain from them. While the picture does include strawberries, grapefruit, and watermelon, the vast majority of the foods are desserts: lollipops, jelly beans, cotton candy, ice cream, donuts, milk shakes, jello, and cupcakes.

Following her trip to the doctor, Pinkalicious suffers various consequences as a result of her altered color: Her friend cannot spot her because she is camouflaged among the pink peonies, a bee mistakes her for a flower and lands on her nose, and she cries for her mother to take her home after bees, butterflies, and birds surround her.

Back at home, Pinkalicious requests and is denied another pink cupcake. After pretending to eat her dinner of “mushy, dark vegetables,” she sneaks back into the kitchen in the middle of the night and devours a cupcake that her mother had hidden. In the morning, a horrified Pinkalicious awakens to discover that her condition has worsened: She is now red.

Desperate to return to her normal self, Pinkalicious says, “I opened the fridge, held my nose, and squeezed a bottle of icky green relish onto my tongue. I ate pickles and spinach, olives and okra. I choked down artichokes, gagged on grapes, and burped up Brussels sprouts.” The accompanying illustration shows a few fruits – limes, honeydew, green apple, and grapes – and a bunch of vegetables, including broccoli, cucumber, celery, asparagus, cabbage, and peas. After ingesting these green foods, Pinkalicious loses her discoloration and becomes “beautiful.”

Left to their own devices to interpret this story, a child has likely internalized the following messages: (1) Pink foods are almost exclusively sweets. (2) Too many sweets will make them sick. (3) Sweets have an addictive-like quality. (4) The way to get healthy is to completely avoid sweets and to instead eat green foods. (5) Green foods are almost exclusively vegetables. (6) Vegetables are yucky. (7) Vegetables make them pretty.

Unfortunately, all of these messages are problematic. Let’s take a look.

Problematic Message 1: Pink foods are almost exclusively sweets.

Plenty of pink foods exist that have zero to mild sweetness, including corned beef, edible flowers, beets, dragon fruit, rare steak, and Himalayan salt, yet the only examples of pink foods that the authors cite are sweets because the former is really just code for the latter.

Problematic Message 2: Too many sweets will make them sick.

Sure, too many sweets can make someone sick, a lesson that I learned on Halloween many years ago. However, we tend to single out and villainize sweets, as if they are somehow the only food group that can sicken us in excess, while ignoring the reality that too much of anything can be detrimental to our health. Remember that even water, when consumed excessively, can kill someone.

Problematic Message 3: Sweets have an addictive-like quality.

Admittedly, this message is more subtle than the others, and I can imagine that it will go over the heads of some children. However, for those of us familiar with the apparent fallacy of sugar “addiction,” we can see its theme in the way that Pinkalicious eats another cupcake despite already having turned pink and gone to the doctor as well as in the lengths that she goes to – deceiving her family, waking up in the middle of the night, and sneaking around – in order to obtain the cupcake. Nevertheless, research suggests that sugar “addiction” is not a true addiction, but rather a byproduct of how we tend to demonize and restrict sugary foods.

Problematic Message 4: The way to get healthy is to completely avoid sweets and to instead eat green foods.

If this general sentiment sounds familiar, maybe that is because our culture oftentimes splits foods into dichotomies and presents one side as sin and the other as salvation. Whole30®, detoxes, “clean eating,” etc., are all based on this basic – and flawed – premise.

Alan Levinovitz, a religion professor who has taken to writing about nutrition because of the intersectionality of spirituality and food, sums up the situation very well, “It’s terrifying to live in a place where the causes of diseases like Alzheimer’s, autism, or ADHD, or the causes of weight gain, are mysterious. So what we do is come up with certain causes for the things that we fear. If we’re trying to avoid things that we fear, why would we invent a world full of toxins that don’t really exist? Again, it’s about control. After all, if there are things that we’re scared of, then at least we know what to avoid. If there is a sacred diet, and if there are foods that are really taboo, yeah, it’s scary, but it’s also empowering, because we can readily identify culinary good and evil, and then we have a path that we can follow that’s salvific.”

Sickness and health are never entirely within our control and are certainly way more complex than eat this, not that.

Problematic Message 5: Green foods are almost exclusively vegetables.

To acknowledge the obvious, yes, many vegetables are green. However, for all the green veggies in the world, we also have pistachios, pumpkin seeds, avocados, and other fruits that the book excludes. Are sweets, such as lime jello and green apple jelly beans included? What about – gasp – green cupcakes? Of course not, and I think we all know why.

Problematic Message 6: Vegetables are yucky.

The attitude that we have towards various foods shapes how our children come to see them. In our culture, adults often teach children to view eating vegetables as a chore. For example, earning dessert by first eating vegetables teaches the child that consuming vegetables is the suffering that one must endure in order to be able to eat what they really want.

My first job as a dietitian was a traveling research position that sent me all over the country examining the foods and eating behaviors in elementary school cafeterias. All these years later, I still remember two specific schools. In one suburban Chicago school, the kids saw eating vegetables as uncool and would not eat them, so the cafeteria monitors would proactively remove the vegetables from the trays for fear that the uneaten veggies would be ammunition for a food fight. Peas were on the menu the day I was there, and I remember seeing the bottom of the trash bin lined with confiscated peas. Meanwhile, eating vegetables was the in thing to do in one northern Tennessee school. The problem the cafeteria workers faced there was that kids were taking too many vegetables from the self-serve salad bar, thereby exceeding the allowed serving sizes. The contrast between these two schools stuck with me because it illustrates how cultural views of a food shape its consumption.

Of course we all have our own unique food preferences and aversions, and some people genuinely just do not care for vegetables, but teaching kids that they are “yucky” is mostly a self-fulfilling prophecy.

Problematic Message 7: Vegetables make them pretty.

“I was me, and I was beautiful,” says Pinkalicious after eating green foods and returning to her normal hue. With beauty being the subjective entity that it is, the use of the first-person perspective is significant and raises questions to which we will never know the answers.

On the surface, this quote reads as a self-affirming statement, but does Pinkalicious – who loves the color pink – really think she looks better now than she did when she was pink, or is she rather expressing relief that her color now matches the necessary criteria for societal beauty standards? In other words, does she really think she is beautiful in her own eyes, or because others – her parents, her doctor, and society as a whole – have taught her that being pink was wrong?

Unsaid but certainly implied is the message that if Pinkalicious returned to her beauty after eating green foods, then she must have been less than beautiful when she was eating pink foods, which tells kids that eating sweets makes them less attractive. If that sounds like too much of a stretch, consider the multitude of my adolescent patients (and sometimes their parents, too) who scapegoat sweets for their acne.

Given how many people – including kids – learn to dislike their bodies and yearn to conform to whatever media, peers, doctors, family, friends, etc., say they should look like, the notion that vegetables can make someone beautiful is surely enticing. The problem is that this message is false. Regardless of what one considers beautiful, no food group has the power to dramatically alter appearance.

Do you really want to indoctrinate your kindergartener into diet culture? If not, make sure that enjoying a reading of Pinkalicious is accompanied with a conversation discussing these messages.

The End Is Near!

Posted on August 30, 2023 by Jonah Soolman

Seven years ago, when I saw Chic in concert for the first time, Nile Rodgers used the interlude in one of their songs as an opportunity to tell the crowd about his recent cancer battle, which he ultimately won. The songwriter and producer explained that receiving the news inspired him to go on a music-making binge, as he figured he only had a short window of time left to express his art.

Earlier today, as I was driving home from the beach with our daughter, that memory crossed my mind. Since she will soon be restarting school, we have been trying to cram in as many daddy-daughter activities and outings – the Museum of Science, the Butterfly Place, farms, the zoo, fruit picking, restaurants, train rides, the aforementioned beach, etc. – as we can before the start of the school year interferes and forces these bonding experiences from frequent occasions to relative rarities. Before we have even left the parking lot of one activity, I am already thinking about the next one and all of the others that I hope to shove into our remaining time before it runs out. We have fun, but part of me is distracted, anxious, and sad as I think about the end.

Deadlines have their upsides because they can push us to accomplish tasks and achieve goals that might otherwise remain unfulfilled, but they bring with them stress and general feelings of unease that detract from the experience.

Life-threatening illnesses and the school calendar are examples of deadlines imposed upon us, realities that we just have to do our best to roll with, but sometimes we needlessly impose deadlines upon ourselves. A person who wants to get married by a certain age may settle because the timing is right even though the partner is wrong. Someone I know recently spent a hot summer evening in the emergency room with heat exhaustion and dehydration because they stubbornly kept hacking away at a tree they really wanted to cut down before dinnertime rather than conceding they should take an additional day to complete the project. When we were adolescents, a friend of mine wanted to bench press a particular weight before a school dance, and he ended up having to fight to free himself as the much-too-heavy bar laid across his chest.

Because this is a nutrition blog, I am of course thinking about the predicaments we can put ourselves and our relationships with food in due to self-imposed deadlines. An obvious example is the melancholy and frantic overconsumption that precedes a scheduled diet. Trying to lose weight before a wedding or another similar function is a common – yet problematic – behavior that is most likely to result in eventual weight gain and increased risk for developing a wide range of health woes. Someone I know severely dehydrated himself on his birthday and spent much of it at the gym because he had set a goal to be at a particular weight by his new age, and while he did survive and recover, he put himself in a dangerous situation for the sake of an arbitrary goal.

Imagine what these scenarios could look like instead without the needless deadlines. No diet on the horizon could mean more peaceful and intuitive eating without the threat of self-imposed food insecurity looming. Foregoing an attempt to lose weight before an event reduces the chances of harmful and discouraging weight cycling and creates space for the person to focus their time and attention on the big day itself and to go into it full of energy instead of depleted. Personally, I can think of more fun ways to spend a birthday than sweating out as much fluid as possible on an elliptical machine.

Time and opportunities are finite resources, and while we never know when they will run out, we can make life easier for ourselves by leaving self-imposed deadlines in the past.

What We Can Learn From Eating While Sick

Posted on July 27, 2023 by Jonah Soolman

We managed to avoid it for over three years, but COVID finally got us. Joanne and I developed strange sensations in our throats virtually simultaneously and then tested positive a couple of days later. Whether due to the disease itself or as a side effect of Paxlovid, we developed terrible tastes in our mouths. Joanne described it as tasting like gasoline, while to me it seemed more a combination of cheese, bad breath, and metal. Additionally, I experienced waves of queasiness and a drastically reduced appetite.

Some of my patients talk about how much easier it is for them to eat intuitively when they are sick versus when they are fully healthy, and my experiences were somewhat similar to their own. When our appetites are diminished and food seems off-putting, our range of tolerable eating options shrinks considerably, which ironically makes food selection easier because foods we are willing and able to eat stand out in greater contrast to the rest.

Sometimes my patients, when they are ill, have an easier time practicing unconditional permission for a couple of reasons. First, because their array of appealing foods is so small, their only realistic option is to go with these foods. Second, because they are sick, they feel they are more deserving of self-care than when they are healthy, so they worry less about their perceived nutritional quality of food or about what they “should” be eating.

Being sick is so unpleasant and disruptive that at least making food choices can be easier for the aforementioned reasons, yet we can learn lessons from eating while sick that we can apply when we are healthy.

Choosing from a vast sea of eating options can be difficult and overwhelming, which is why deciding what to order from the Cheesecake Factory’s massive menu can be challenging. It is why, when our daughter demands “Choices!” when I ask her what she wants for a given meal, I offer her a small selection of different foods. We do advocate for having a wide variety of foods on hand at home so we have a reasonable shot at being able to satisfy whatever criteria our intuitive eating questions lead us to, but selection can nevertheless be hard if every option feels appealing. As when we are sick, having a smaller range of options that sounds good can make the process easier, but we can accomplish the same objective without being ill by eating before the magnitude of our hunger grows to unwieldy levels.

Only some of my patients utilize a hunger/fullness continuum, as it can sometimes be counterproductive if misused, but those who do know that we define a “3” as a comfortable hunger where we are ready for a meal and we are able to discern which foods sound like they will best hit the spot. In contrast, we define a “2” as a hunger that has grown uncomfortable, where we may feel irritable and stressed, and choosing what to eat can be especially challenging because our bodies are essentially telling us, “I don’t care what you feed me, just give me food!”

By eating before we get to a “2,” we give ourselves an opportunity to separate the most appealing foods more easily from the rest of our options. The practicalities of real life sometimes preclude us from being able to have our meals and snacks exactly when our body’s hunger cues suggest we are best off eating, but through experience, we can learn how to incorporate well-timed snacks that have us arriving at mealtime comfortably hungry rather than ravenous.

In terms of unconditional permission and the relative ease with which we can practice it when we are sick, remember that we are always deserving of self-care – including having the freedom to eat what, when, and how much we want without justification – regardless of our state of health. Think of self-care as something to be practiced not just when we are ill and need to get better, but also when we are already well and hope to stay that way. Personally, I can remember many times over the last few decades when I put self-care to the side, disregarded what my body was asking for, and ended up in a state of illness that was arguably avoidable if I had taken better care of myself.

Next time you are sick, consider the lessons about your eating that you can take with you as you leave the illness behind.

The Problem With Fat Shaming Professional Athletes

Posted on May 29, 2023 by Jonah Soolman

Felger: If we ever get to the point where we can’t fat shame athletes, I quit.

Massarotti: It’s coming.

Felger: It is coming.

Massarotti: It might already be here already.

Felger: It’s not. We’re not talking about a teenage girl. We’re talking about professional athletes whose job it is is to be in shape. We are allowed to call them fat and tease them for being fat. If that becomes off limits, I’m done.

The aforementioned exchange, which took place in the context of discussing Kyle Lowry of the Miami Heat, occurred between co-hosts Michael Felger and Tony Massarotti near the end of their Felger & Mazz sports talk show on May 17, 2023. Much like the fat shaming directed at Pablo Sandoval seven years ago, this problematic dialogue misses the mark and causes harm.

Felger asserted that part of a professional athlete’s job is to be in shape, but what constitutes “in shape” should not be defined by anthropometrics, such as weight or body fat percentage, but rather by an athlete’s readiness to perform their given sport at the level their employers expect of them. If an athlete lacks the strength, endurance, or flexibility to perform, the deficiency in their fitness is the real issue regardless of how their body is built; otherwise, teams would just fill their rosters with bodybuilders and models and call it a day.

“In shape” is also context dependent, as the physical abilities necessary to perform at a high level vary from sport to sport. A gymnast who lifts weights and runs but never stretches, a shot putter who stretches and runs but never lifts, and a marathoner who stretches and lifts but never runs would all have serious issues with their performance regardless of how their bodies look.

Besides, Kyle Lowry is actually quite a good basketball player. Lowry is in the midst of finishing his 17th season in the NBA, he earned spots in six straight All-Star games from 2015 to 2020, he started all 65 regular season and 24 playoff games that his team played on their way to winning the 2019 championship, and he was a member of the USA Olympic team that won the gold medal in 2016. Sure, his statistics dropped off a bit this season, but blaming the dip on his physique – which looks to be the same now as it did four years ago – is a bit of a head-scratcher considering the 37-year-old is the seventh oldest player (out of approximately 450) in a league where the average player is 26.01 years old. According to basketball-reference.com, Lowry’s career performance arc is thus far most similar to those of Terry Porter, Vince Carter, and Allen Iverson, the latter of whom is already enshrined in the Hall of Fame, and another – Carter – will likely get in too once he is eligible.

Lowry is far from the only “fat” athlete to outperform many of his leaner peers. The aforementioned Sandoval made over $73 million during his 14 years in the major leagues, and the two-time All-Star was named Most Valuable Player in one of the three World Series that his teams won. Pat Maroon was fat shamed despite winning three straight Stanley Cups. Back in Lowry’s realm of basketball, Luka Doncic’s own boss criticized him for his weight despite winning Rookie of the Year, then being named an All-Star and making the All-NBA first team in the four seasons he has played since then.

However, the most concerning part of Felger’s opinion is that he seems ignorant of the impact that his sentiments have on people other than professional athletes. “We’re not talking about a teenage girl,” he said, but the reality is that fat shaming anybody breeds fat shaming in general. Discussing the reasons why criticizing Donald Trump for his weight is harmful, Ragen Chastain explained, “And make no mistake, when you engage in fat-shaming, your victim is every single fat person.” The ramifications of fat shaming athletes are clear, as I discussed in the Boston Baseball article I wrote about Sandoval back in 2016.

“Fans and media have labeled Sandoval ‘disgusting,’ ‘lazy,’ and ‘pathetic,’ implying that those same terms apply to everyone who has a body type similar to his.

The message is that fat is to be loathed, that larger individuals are not worthy of the respect enjoyed by the rest of us. We reject stereotypes based on race, religion, ethnicity, or sexual orientation but we inexplicably tolerate those based on body size.

The idea that we can tell how someone eats or exercises based on his shape or weight is a myth. Some people built like linebackers never lift weights. Some skinny-as-a-rail folks subsist on fast food. And some obese individuals are more active and have a healthier relationship with food than any of them, but inhabit bigger bodies for other reasons.

As we all know, pressure to be thin leads to dieting, which can lead to a variety of problems, including eating disorders. These life-threatening illnesses are so common in Massachusetts that if the crowd at a sold-out Fenway Park represented a random sample of the state’s population, those in attendance with a diagnosed eating disorder would fill section 41.”

Sounds like Felger’s intent was to focus his fat shame on professional athletes while sparing others – and good thing it was, for his behavior would be even more problematic if his intent was otherwise – but we all know that intent and impact are two different entities. Felger certainly should know this, as his co-host was suspended just three months ago for making a poor attempt at humor that came off as racially insensitive. Like Massarotti, Felger should have known better.

If Felger is unwilling to forego fat shaming professional athletes, then the time for him to quit truly has arrived.

Gentle Nutrition

Posted on April 28, 2023 by Jonah Soolman

What is gentle nutrition? Imagine a Venn diagram. In one circle, we have intuitive eating, which is an approach to making decisions about what, when, and how much to eat centered around our body’s internal cues. In the other circle, we have medical nutrition therapy, which is the use of nutrition to treat various health problems. In the area in the middle where the two circles overlap lives a concept that we call gentle nutrition.

For my patients who are working to rebuild their intuitive eating skills, getting a firm handle on what gentle nutrition means and how to implement it in their lives are often two of the trickiest steps they face. The most common reason is that people oftentimes do not trust that their body’s internal cues will steer them in the direction of eating in a way that is conducive to their health. This fear, which I otherwise think of as the “If I allow myself to eat whatever I want, all I will do is have [insert the name of your taboo food] all the time” expectation, implies that eating for health means overriding intuitive eating cues.

My counter to that concern is to cite the food journal analyses that I perform on some of my patients. When I look at the intakes of my seasoned intuitive eaters, their nutrient consumption almost always falls within their estimated needs because their body naturally guides them towards the food it requires. In other words, my clinical experience suggests that when we eat intuitively, the eating-for-health part largely takes care of itself.

But what if our body is an imperfect guide? What if we face a gap between how far our intuitive eating takes us and where medical nutrition therapy suggests we should be?

For starters, take a step back and remember that our behaviors have limited influence on our health. One of my patients recently told me about a colleague who was diagnosed with cancer, and as word spread around the office, her co-workers reacted with surprise because the woman is so “thin and healthy.” (And as my patient astutely pointed out, if her colleague was fat rather than thin, people likely would have felt that she brought her health woes upon herself, which is a whole other problem.) Hearing the story reminded me of a fellow healthcare practitioner who was diagnosed with cancer herself despite being clearly orthorexic. For people who erroneously believe that they can control their medical fates if only they engage in certain behaviors, counter examples like these can rock their world.

Given that we may suffer whatever ailment we hope to avoid regardless of our best efforts to steer clear of it, we have to consider the lengths that we are willing to go to – and what we are willing to sacrifice – in hopes of reducing our risk. Focusing on medical nutrition therapy may sound sensible in theory, but doing so can come at the expense of our relationship with food. Consider the following scenarios that someone with hypertension might face.

What if you feel like you should never have salty food because of your high blood pressure, or when you do allow yourself to have it, you feel like you are being “bad”?
What if you have a history of restriction and the mere thought of cutting down on salt feels traumatic?
What if you are a recovering binge eater and stocking salty foods is an important step in your treatment?
What if you are on the road and happen upon a restaurant famous for a high-salt dish you really want to try, but you feel like if you do, you are asking for a cardiac event?

Who wants this level of angst interwoven with their eating when the fact of the matter is they could die of a heart attack no matter how much or how little sodium they consume? Unfortunately, stress, guilt, second-guessing, and inner turmoil can be significant issues when we practice not-so-gentle nutrition.

We advocate for gentle nutrition because of the downsides that come with focusing too hard on medical nutrition therapy and because of the upsides of taking a more moderate approach that still respects intuitive eating. Consider how someone practicing gentle nutrition would approach the same scenarios that I listed earlier.

What if you feel like you should never have salty food because of your high blood pressure, or when you do allow yourself to have it, you feel like you are being “bad”? They understand that complete abstinence of salty food is neither necessary nor practical, and they can enjoy such foods without guilt.
What if you have a history of restriction and the mere thought of cutting down on salt feels traumatic? Before even tackling gentle nutrition for their blood pressure concerns, they first do the necessary work to heal their relationship with food, thereby making medical nutrition therapy feel less triggering.
What if you are a recovering binge eater and stocking salty foods is an important step in your treatment? They recognize that in order to make peace with salty foods and get to a place where “a little” does not automatically turn into “a lot,” they have to practice unconditional permission and abundance, which entails exposure, continuous access, and predictable overconsumption for a period of time.
What if you are on the road and happen upon a restaurant famous for a high-salt dish you really want to try, but you feel like if you do, you are asking for a cardiac event? They understand that no single eating experience is going to save nor doom their health, that food is part of culture and travel, and that they would probably regret forgoing a rare opportunity.*

How then is the nutrition part of gentle nutrition implemented? That same person with hypertension may use their intuitive eating cues to determine that they feel like having a piece of fruit for a snack, but both the apple and the banana sound equally appealing, so they opt for the latter since it has more potassium than the former. On the other hand, if they feel like solely the apple would hit the spot, they eat it, enjoy it, and look for other places in their day to get their potassium. If the whole day goes by without consuming much potassium, they do not worry, but rather trust that their intuitive eating cues guide them in different directions day to day, and tomorrow they could very well find themselves taking in a high amount of potassium.

After reading all this, you might be thinking to yourself, “Yeah, okay, I get that my health is not entirely within my control, but I want to do everything I can to minimize my risk.” If so, that is entirely your right. You are the expert in your own life, nobody is in a better position to decide your path forward than you are, and I commend you for weighing the pros and cons and making an informed decision that feels right for you.

However, that same autonomy applies to each of us, and many people conclude that not-so-gentle nutrition is just not worth its cons and that gentle nutrition is the way to go.

* Speaking from personal experience, I remember spending a night at a church on a Native American reservation in Montana during my Seattle-to-Boston bicycle trip. My hosts offered me one of their traditional dishes – something that I can only describe as a French-fried donut, although I am sure that is not at all what it was – and it turned out to be literally the best tasting food I have ever had in my life. Sometimes I think about what I would have missed had I turned down the food due to nutrition concerns.

Pancakes

Posted on February 23, 2023 by Jonah Soolman

Some months, coming up with a newsletter topic is unusually challenging. For the last few weeks, Joanne and I were both scratching our heads, as the ideas we had were for research pieces that would demand more time than either of us is able to dedicate at this point in time. Being silly, I facetiously asked our four-year-old daughter what I should write about this month. “Pancakes,” she responded, “Pancakes and maple syrup.” Joanne and I laughed, and I walked out of the room, but I quickly returned and told them I was going to use her idea.

Our daughter’s suggestion reminded me of a quote from one of my earliest patients many years ago, and what the latter said to me felt significant enough that I wrote it down as soon as she left my office. “One day, you will have a baby boy who will love you,” my patient said, “and then he will grow up to hate you. But then one day he will love you again and say, ‘Hey, Dad, let’s go out to breakfast, just us guys,’ and then you will go to Bickford’s, and you will have an apple pancake, too.”

At that point in my career, I was still doing the kind of work that most people figure dietitians do: putting people on diets in the pursuit of weight loss. My prescribed diets were low in carbohydrates, especially grains, and so restrictive of calories that if my patients were living in a different region of the world, the United Nations would have sent cargo ships full of food to help them. While I did not author these diet plans, which seemed concerning to me at the time because of their restrictive nature and the good/bad food dichotomy they established, I did dole them out as instructed, and for that I have nobody to blame but myself.

These diet plans typically “worked” in the sense that my patients lost weight, but rarely – if ever – did the weight suppression last long term. At the time that I left the medical center where I was working and stopped doing that kind of work, I did have some patients who had maintained their weight loss thus far, but I have no idea what happened to them later. Given that most weight regain happens two to five years after baseline, I can only assume that at least some of these patients, if not all of them, regained weight after I was out of the picture.

Diets fail for a number of reasons. Most significantly, the physiological mechanisms that kept our ancestors alive through periods of starvation kick in when we restrict and promote weight regain. Another factor, the one that my patient was trying to make me aware of via her aforementioned quote, is that diets are incompatible with real life. After all, if I were following the low-carb, low-grain, low-calorie diet that I had put her on, I would be unable to both remain on the plan and partake in her breakfast scenario. The dietary expectations I had set out for her were unrealistic, which was exactly the point she was trying to get me to see. Point taken.

Now that I am a dad myself, I have greater first-hand life experience to reinforce my theoretical understanding. Numerous times over the last few years, I have eaten foods I was not in the mood for because sharing an eating experience with my daughter was more important to me than eating exactly what I wanted. For example, the food at Chick-fil-A rarely sounds good to me, and I certainly would have preferred something else for dinner last Tuesday night, but I took her there because she loves it, she asked me if I would take her, and I prioritized making her happy and sharing one of her favorite meals over eating what I really wanted.

If I was on some diet plan that restricted foods like Chick-fil-A, such as the plan I had given to the patient in question, I would have had to choose between breaking the diet or missing out on a family bonding experience. When I was a young adult and somewhat orthorexic, I prioritized “healthy behaviors” to the detriment of other important areas of my life. After turning down plans with friends so I could exercise after work and go to bed early, some of them began to distance themselves from me and stopped extending invitations. My insistence on only eating food I had brought from home kept me from joining co-workers for lunch, and my rapport with them weakened. If you have ever been on a diet yourself, consider the ways in which sticking to the plan came at the expense of other facets of your life. My guess is that if you look back, you will find examples in your own life similar to the ones I just described.

Furthermore, remember how you felt when you inevitably deviated from your diet. In Reclaiming Body Trust, authors Hilary Kinavey and Dana Sturtevant succinctly describe the pattern of dieting with a diagram that they entitle “The Cycle.” At the 12 o’clock position, the circular diagram begins with “The Problem,” which then leads to “The Shame Shitstorm” at three o’clock, followed by “The Plan” at six o’clock, then “Life” at nine o’clock, and then back to “The Problem” as the pattern indefinitely repeats. Delving into the particulars of these positions is beyond the scope of this blog, but the overall pattern is one to which many of us can relate: We identify a problematic eating behavior, feel bad about it, desperately grab for a plan that will supposedly rescue us from ourselves, abandon the plan when it proves itself to be incompatible with life, and the cycle repeats.

If a diet puts us in a position to choose between (A) sacrificing important parts of life, such as sharing a bonding experience with our kids, in order to remain on the plan, or (B) breaking the diet and perpetuating a cycle of shame and unsustainable attempts to deal with our problems, then perhaps dieting and living a full life are simply incompatible.

A Few Scattered Thoughts

Posted on January 24, 2023 by Jonah Soolman

A few scattered thoughts as we settle into 2023 . . .

Caroline Garcia, a French professional tennis player ranked fourth in the world as of this writing, recently went public about her struggles with bulimia. She reportedly explained, “Everyone is different. Some don’t eat anymore, I was the opposite: I took refuge in food. These were times of crisis. You feel so empty, so sad, that you need to fill yourself up. It was the distress of not being able to do what I wanted on the court, no longer winning and suffering physically. Eating calmed me down for a few minutes. We all know it doesn’t last, but . . . It was an escape. It’s uncontrollable.”

She and I have never worked together, met, nor communicated with each other in any way, nor am I familiar with the particulars of her medical history and eating disorder history, so of course I am only speculating, but it sure sounds to me like she still has a ways to go in her recovery. For example, her discussion of “temptations” in the players’ restaurant suggests that she still might have some trigger foods and/or a dichotomous view of foods in which her mind sorts them into groups of good and bad.

Having said that, one of the positive steps she has taken towards recovery is allowing herself more freedom in her eating. For example, she is quoted as saying, “Now, if for two days, I want a pizza, I’ll take my pizza and it will stop obsessing me.” With every eating disorder – whether bulimia nervosa, anorexia nervosa, binge eating disorder, or anything else – removing restrictions is always part of the solution.

–

While I was lifting weights at the gym earlier this month, I overheard two high school boys questioning the bench press technique that their muscle-bound trainer was teaching them. Seeking a second opinion, the trainer asked another young man who responded to the boys, “This guy knows everything! Look at him; he’s a beast!” The boys were right to second-guess their trainer, whose directive to bounce the bar off their chest increases the risk of harm and decreases the exercise’s effectiveness.

The more macroscopic problem exemplified here is that some people continue to make the mistake of confusing appearance with expertise. Nearly a decade ago, I gave a presentation that I called “Looking the Part: Patients’ Size-Based Biases Toward Their Practitioners and How to Handle Them” at the 2015 Association for Size Diversity and Health (ASDAH) conference. As I prepared my talk, I found research indicating that patients make all sorts of appearance-based judgments about their practitioners. For example, patients indicated they were much more willing to discuss sensitive issues like their psychological, sexual, and social problems if their doctor was wearing a white coat. Research also shows that patients make assumptions about their caregivers’ abilities based upon age, gender, hairstyle, and even whether or not the practitioner is wearing a name tag. If some patients prejudge a practitioner’s expertise based upon something as silly as the presence/absence of a name tag, then it should come as no surprise that research shows that patients also make assumptions based upon a practitioner’s size.

Having been a personal trainer myself, I can tell you that clients and potential clients hold similar biases based upon a trainer’s size, physique, athletic achievements, and other factors, when really none of that has anything to do with a given trainer’s expertise and capacity to help the client at hand. My client load grew immensely after I rode my bicycle from Seattle to Boston because people assumed that I must be a great trainer if I could accomplish something like that. While I appreciated the uptick in business, the premise behind it was ridiculous, as I was certainly not a better trainer upon my return than I was before I left for my trip. If anything, I was probably worse due to the exercise science knowledge I forgot while I was away.

Trainers often – but certainly not always – have lean and/or muscular builds, but that does not mean they hold some secret that will help their clients to attain similar results. Because of their biases, potential clients tend to gravitate towards trainers who have the type of bodies they want for themselves, while other trainers, who might be great trainers in actuality but fail to look the part, starve for clients before ultimately switching professions. Furthermore, size-based bias also prevents some potential trainers from entering the field, such as a patient of mine who wanted to be a CrossFit coach, but she did not think she would be successful because of her body size.

The truth is that appearance and expertise are independent entities. Conflate the two at your own risk.

–

Back in November, I wrote a piece about a college buddy who recently died after being hit by a car. Shortly after publishing it, and thanks to some feedback that I received from a longtime friend, I realized that I made a mistake similar to the very one that I was criticizing. Whereas some people jump to blaming the victim without enough information, I did basically the same thing by blaming the perpetrator without taking into account the bigger picture.

We live in a society in which following the law is a suggestion that can be disregarded with little fear of consequence. Examples are numerous, but for the sake of brevity, here are a few that immediately come to mind: doctors who blatantly and knowingly commit insurance fraud yet are still impaneled; above-the-law politicians who are still in office instead of prison; maskless police officers, train conductors, and transit drivers who defied the mask mandate rather than enforce it; ubiquitous underage drinking; and dog owners who behave as if their pet is too special for the leash law.

My daughter used to like to watch cars and trucks, and I would see many drivers holding their phones despite the hands-free law that had gone into effect. Drive the speed limit and watch the line of tailgating traffic elongate behind you. Do pickup trucks even come with turn signals?

Sometimes I wish we had a list of the laws that we are actually supposed to abide by and those that are just for show so everyone could be on the same page. As it stands, each of us picks and chooses which laws to follow and those from which we rationalize our special exemption. The absence of both consistent enforcement and appropriate modeling from our leadership has neutered our system of laws. We tolerate this, and I have no idea why.

We also seem to be okay with huge billboards that are designed to literally distract drivers from the task at hand for the sake of capitalism. We could have floodlights that illuminate a crosswalk when a pedestrian pushes a button, but we do not. Instead of crosswalks, we could have underground passages or overhead walkways to avoid the risk of a car and pedestrian ending up at the same place at the same time, but such structures are rare. Instead of blinking little yellow lights or flashing red lights, we could have normal traffic lights that turn solid red for pedestrians in crosswalks, but I only see these at intersections where cars have to stop for each other anyway. Better yet, we could install the kind of solid red lights that have white strobe lights in the center for increased visibility, but these are few and far between. Guys, things do not have to be this way.

So, here comes my friend, a father of two young girls, entering a crosswalk unequipped with any of these aforementioned safety measures, on his way to meet his wife for dinner. And here comes the teenager – who has grown up and learned to operate a vehicle in a society that has normalized careless driving and repeatedly set the example that following the law is a personal choice rather than a requirement – who will soon kill him. Maybe it helps us to feel better to condemn the driver, to act as if their behavior is somehow an exception to the norm, and to claim that they alone are responsible for my friend’s death. The truth, though, is that we all are.

Blaming the Victim

Posted on November 22, 2022 by Jonah Soolman

Perhaps you caught last month’s news story about a tech CEO who was hit by a car and killed crossing a street in Acton. He was a friend of mine from college. The driver took away a leader from a company, a husband from a wife, and a father from two young daughters, and severely derailed the trajectory of their own life in the process.

Some of the details omitted from the published story include that he was crossing the street to meet his wife for dinner and that the driver hit him while he was in a crosswalk. Try telling that to the internet trolls who left some ignorant comments suggesting that my friend may have been looking at his phone or crossed without looking.

Their comments got me thinking, and I remembered that blaming the victim is largely about fear. Admitting that we have limited control over our fates is scary, so much so that some of us find some comfort in assuming that a victim must have made some error and brought their end upon themselves.

Looking back, I experienced some of this myself with my three back surgeries. When I had the first operation to remove a tumor, some people questioned how I could possibly have developed one and suggested that I must have grown up under high voltage wires or that I did not take care of myself. No, my environment was fine, I was an athlete, and I had a balanced diet (by adolescent standards). When I had my first spinal fusion, some people assumed I must have done something stupid in the weight room to necessitate the repair, but no, it was really just the fallout from a freak accident and residual structural issues from the tumor. The next year, when I had to have a second fusion because the first one did not work, some people figured the surgeon must have screwed up or that I did something wrong with my rehab. No, sometimes surgeons do everything right and the patient can look on paper like the ideal candidate to heal well, and yet, in a small percentage of cases – including mine – problems still arise.

Our health is no exception to the reality that our outcomes are only somewhat in our control. We live in a culture that blames “overweight” people for their size, that if they only were disciplined enough to eat less and exercise more that they would be thinner, while the reality is that long-term weight regulation is largely regulated by factors unrelated to our behavior. We look at scary diseases and hope we can ward off morbidity and mortality by creating and avoiding dietary demons, yet people of all ages and behavior profiles still get sick and die.

A few days after my friend was killed, my daughter and I had a close call ourselves while I was walking her to school. We got to a crosswalk, I hit the button to activate the flashing yellow lights, the cars in both directions stopped for us, and we began to cross. Before we could make it across, an SUV pulled out from the school’s driveway. Perhaps the driver saw the stopped cars and thought they were waving her in. Regardless, without looking in our direction, she turned onto the street towards us and hit the accelerator. I started running, and it was a close enough call that I arched my back in order to avoid the corner of her front bumper. When I glanced back at the driver, she looked horrified. As we continued on our way, the driver repeatedly yelled to us, “I’m so sorry!”

I was angry, just as I was when I heard my friend died. I was angry at both drivers, and I was mad at our society that normalizes and enables careless driving. However, beneath my anger was fear. We live in a world in which someone can do everything right and still have things go very, very wrong, which is horrifying, and we attempt to shield ourselves from this fear by assuming that victims brought their fates upon themselves.

Mindful Eating vs. Intuitive Eating

Posted on October 24, 2022 by Jonah Soolman

In one of my recent blogs, I mentioned in passing that mindful eating and intuitive eating are different concepts, a topic that I am circling back to now because I frequently meet new patients who mistakenly believe they are synonymous.

Intuitive eating is an approach that leans upon our body’s internal cues and uses them to drive decisions regarding what, when, and how much to eat. People who eat intuitively generally use sensations of hunger and fullness to determine when to eat and the quantity of food to consume at a given time, and they may utilize a series of matching questions to determine which foods are going to best hit the spot. (Note the words “generally” and “may,” which I have included to reflect that intuitive eating is a set of guidelines that one can use to the extent that they find helpful, not a set of rules that must always be followed.)

Mindful eating, on the other hand, is broader and simply entails paying attention to one’s eating. Intuitive eating falls under the umbrella of mindful eating, but plenty of other versions of mindful eating exist. For example, one could mindfully portion out their dinner as they carefully strive to stay within the day’s points budget. One could be mindful of the texture and flavor of their Halo Top while wishing it were Ben & Jerry’s. One could mindfully savor every bite of their 100-calorie snack pack while knowing they are hungry for more food than they are going to allow themselves to have.

One must be mindful in order to notice internal cues, but one can be mindful of other things while completely ignoring what their bodies are telling them. In other words, one can eat mindfully without eating intuitively, but one cannot eat intuitively without eating mindfully.

If you have thought to yourself that you wish you ate more mindfully, consider looking deeper to discover what it is that you are ultimately hoping to achieve. If weight loss is the motivation, then mindful eating is likely just code for dieting, an attempt to put a rosier package around restriction while the contents remain the same. On the other hand, if recovering from disordered eating or establishing a more peaceful and healthy relationship with food is the goal, then intuitive eating specifically – not mindful eating in general – is the path forward.

So, what exactly do future dietitians do at a dietetic internship?

Posted on September 28, 2022 by Jonah Soolman

Just a few months after passing my exam to officially become a registered dietitian (RD), one of my former professors asked me to come back to the University of Massachusetts Amherst (UMass) to talk with some of her nutrition students about my training and the process of becoming an RD. At one point, she asked me to talk about my dietetic internship. While I have no idea what I said, she could tell that I was holding back, and she interjected and assured me it was okay to be candid. So I gave it to them straight: My internship was the worst year of my life.

Before I get to why the experience was so horrible and what I learned during it, first let me introduce what a dietetic internship is and how it fits in with a budding RD’s training. Somewhat similar to a medical residency, a dietetic internship is a bridge between school and becoming a full-fledged healthcare practitioner. Unlike school, where students study concepts in an academic setting, internships provide hands-on opportunities to perform the roles of a dietitian while under supervision. Only after finishing their schooling can one begin an internship, and only after satisfactorily completing their internship can one sit for the exam to become an RD. The internship, in another words, is a required step in the career path.

Applicants indicate the programs they are interested in and rank them in order of preference, the internship programs themselves similarly rank their applicants, and then a computer figures out the matches. Placement in an internship is not a guarantee – one statistic that I read estimates that only 60% of applicants each year are matched to an internship – and I remember classmates who applied multiple times without ever receiving a match. No internship means no career as a registered dietitian, a reality that I feel should have been mentioned at the beginning – rather than towards the end – of nutrition school so students would have adequate time to formulate a plan B. The computer matched me to Boston’s Beth Israel Deaconess Medical Center (BIDMC), which I had listed as my first choice.

Internships typically include rotations in clinical care, community nutrition, and food service settings, but the exact composition varies from program to program. For example, one of the internships I know of has an added focus on business while mine emphasized medical nutrition therapy. Each setting includes multiple rotations that give an intern a chance to perform a variety of duties in a range of settings. Most of my rotations took place at BIDMC, but some were off site in the surrounding community.

Food Service Management

My internship began with a rotation in food service management, which had me working in the hospital’s cafeteria. My tasks ranged from culinary duties, such as learning how to efficiently chop vegetables and then applying these skills by dicing about 60 pounds of winter squash, to studying the technical specifications of various pieces of industrial kitchen equipment. At no point in my career have I ever needed to know the details of the Alto-Shaam Combitherm Model 12-18ESG flash-steam combination oven/steamer, but for a few weeks of my life, I could have told you all about it.

They told me to spend an hour working one of the cafeteria registers. After about 45 minutes, I had developed a whole new appreciation for cashiers and the pain and degradation that they tolerate. While ringing up purchases and processing payments was straightforward, the boredom and rude customers led me to conclude that there is no way I would last long doing checkout.

One of my tasks was to design and implement a nutrition promotion in the cafeteria. For whatever reason, I chose lycopene, a chemical compound found in some fruits and vegetables, so I put together table tents, a PowerPoint presentation that I projected on a cafeteria wall, and other educational materials for our customers. Additionally, I created special menu options high in lycopene, such as stuffed red bell peppers and cherry tomatoes, to coincide with the day.

While I enjoyed the food service courses that I took in nutrition school, my food service management rotation was unpleasant and awkward. In no way do I look down upon people who perform manual labor, nor am I above doing such work myself; when I worked as a personal trainer, I spent extra hours at the gym washing towels, mopping floors, and wiping down equipment, and I found pride, enjoyment, and satisfaction in maintaining a clean and orderly environment for our members. But the interpersonal dynamics at the hospital were based on a hierarchical structure, even in the kitchen, which suggested not so subtly that some jobs – and therefore some people – were more important than others when in reality they are all necessary for the hospital to properly function. Shadowing a line cook for a few hours so he could teach me about his job before I moved along to more “important” duties while he continued to make food felt like disrespectful cosplay, which did not sit well with me.

Being an intern, I was considered pretty far down the pecking order myself. On the day of my special menu, my preceptor got mad at me because the menu ingredient list read cherry tomatoes while the dish that she assumed was mine contained chopped tomatoes. As she was laying into me, I realized that the discrepancy involved a different dish, one that was not part of my special, and the ingredient list for my entree was in fact accurate. She did apologize, but the incident illustrated her general attitude towards interns and her employees, which was to pass judgment before having an understanding of a given situation or behavior and to hold a default presumption that those under her were inept.

Patient Food Service

Lucky for me, my patient food service rotation was at a different BIDMC campus, and my preceptor this time around was great. She welcomed questions, invited my input, and even gave me her home telephone number so I could call her while she was out of the office if I needed something.

My duties included putting together patient meals, checking the trays against their order forms to ensure accuracy, and delivering the food. The room service associate – the job title for the people who deliver food to patient rooms – that I shadowed was great and demonstrated how to appropriately address the patients. Knock on the door, even if it is wide open, to alert the patient that someone is coming. If a medical professional or a visitor is present, discreetly and quietly leave the tray on the bedside stand. Otherwise, greet the patient and quickly leave unless they have questions or comments. Such guidelines may or may not seem obvious, but as someone who had never worked in a hospital before, I was grateful that she took the time to teach me proper etiquette.

As an intern, I was required to dress business casual and wear a white lab coat no matter what I was doing, even when I was delivering trays. Consequently, patients often seemed confused when I walked in wearing a lab coat and carrying a tray of food. On at least one occasion, someone mistook me for a doctor. The confusion was so immediate that some patients were already perplexed by the time I could identify myself as from the food services.

While working in the “nourishment kitchen” processing and preparing patient supplement orders, I sampled each supplement myself on the advice of my supervisor, as she felt that it was important for me to have tried them so that I could relate to the patients who needed to take them. Patients occasionally asked me for advice regarding which supplement flavor to choose, and I also noticed their moods improve when they complained about a given supplement and I was able to empathize because I had tried the same drink myself. Had I not sampled the supplements, these quality patient interactions would not have taken place.

Another series of taste tests involved ordering trays for myself as I tried to put myself in the position of patients who were on special diets. Selecting a complete and satisfying meal while satisfying the constraints of a strict sodium restriction was difficult, almost as challenging as consuming pureed turkey and broccoli and thickened orange juice.

One of my tasks was to interview 20 patients on various hospital floors about the food. The opinions tended to be a matter of perspective. Generally speaking, those who evaluated the BIDMC food in relation to other institutional food spoke very highly of it, while those who compared it to restaurant food were typically disappointed. While I found it interesting to hear what patients had to say about the food, the part of the experience from which I learned the most was simply talking with them. As one patient told me when I asked him about the food, “I have bigger things to worry about than the food,” pointing to a surgical scar and tubes protruding from various places in his body.

Clinical Care

Shortly after finishing my internship, I called a colleague whom I had met during the experience to discuss the next step in my career. Referencing the tradition that new dietitians are supposed to pay their dues by working in a clinical setting before moving on to other areas of employment, I told him, “I know I am supposed to work in clinical, but . . .” “Stop right there,” he said, cutting me off. He went on to explain how outdated and nonsensical this tradition is, as clinical work has little to do with other areas of nutrition. He was right.

The three things I like to do that are the reason I decided to pursue a career in dietetics are getting to know patients, talking about food, and facilitating long-term behavior change, yet rarely does a dietitian do any of them in a clinical setting. Forget getting to know patients, as mine were often asleep, sedated, or otherwise unable to communicate, and my interactions with them were typically limited to entering their rooms and gathering whatever data I needed from their bedside medical devices and their chart notes. Forget talking about food, as my patients were frequently unable to eat and were instead relying on nutrition via enteral (i.e., a tube or port into the gastrointestinal tract) or parenteral (i.e., a line directly into the blood stream) feedings. And forget facilitating long-term behavior change, as the goal was almost always just to get the patient well enough for discharge.

My clinical rotations took place at BIDMC, Boston Children’s Hospital, Somerville Hospital, and the Youville Hospital and Rehabilitation Center. The only memory that stands out to me regarding the last two rotations is that I remember eating lunch with one of my preceptors and commenting that I appreciated her sitting with me, as we were specifically told not to eat lunch with the BIDMC clinical dietitians, who did not want to sit with their interns. She told me that those dietitians should be embarrassed and ashamed of themselves.

Generally speaking, my duties at BIDMC, whether I was in the ICU, the transplant ward, or another unit, entailed gathering data from a patient’s medical chart – particularly their lab work – and then using it to make recommendations regarding their nutrition prescription. Patients who were eating, but still needed some nutrition support, typically saw a diet technician, who could offer some suggestions regarding supplements, such as Ensure. In contrast, RDs and we dietetic interns treated sicker patients who were usually not eating and instead needed the aforementioned enteral or parenteral (TPN) methods of nutrient intake. TPN formulations often required daily tweaking depending on a patient’s labs, so I would look at their blood results, come up with my recommendations, run them by my preceptor, and then call down to the pharmacy and direct them as to how to construct the composition of that patient’s TPN mix for the day. Sometimes I also made recommendations for supplementation, like banana flakes for a C. diff infection or zinc for a pressure ulcer. This is where I learned that giving too much zinc for too long can create a copper deficiency, as the two minerals compete for absorption.

Some specific moments stand out in my memory, such as the time I was present for a tracheotomy, which was way bloodier in real life than on television. As I was backing away from the patient for fear that I was about to faint, the doctor told me, “Don’t be shy, get right in there!” Another day, I arrived to find the unit abuzz with many of the nurses and residents giggling and talking quietly to each other. After asking around, I learned that they were readying to squirt warm maple syrup up a patient’s butt.

Other standout memories are humorless, like the time I was working in the ICU and went to assess a patient, but their nurse told me not to bother, as they were unlikely to survive the day. The last patient that I ever treated while I was an intern had terminal cancer and was barely eating. She quietly responded to my suggestions, none of which would have made any sort of meaningful difference. They never prepared us for how to respond to death or to talk with patients who were on its verge and their families. We were left to come up with the answers ourselves, and I am quite certain mine were lacking.

My rotation at Boston Children’s Hospital was perhaps the most miserable stretch of the internship, largely because I was directed to treat patients right off the bat before I felt I had a solid enough understanding of pediatric care. The dietitians acted like we interns were an annoyance and a disruption to their work – which, granted, we probably were, but that was not our fault – and questions often did not go over well. My preceptor seemed generally bitter about her situation, as she really wanted to be a doctor, but settled for becoming an RD because she did not think she could handle medical school. Her story was not unique, as I met quite a few dietitians working in clinical settings who wanted to be doing something else. It reminded me of freshman orientation at Tufts University, a place to which I had applied early action because it was the only college I wanted to go to, and I was surprised by how many of my peers were disappointed to be there, as Tufts was their safety school that they had to fall back on after failing to get in any of the Ivies.

As was the case in nutrition school, we got very little eating disorder training during the internship. One of my rare exposures occurred at Children’s, as I remember shadowing a dietitian who was gently trying to convince an anorexic girl to drink some milk. The girl – wearing a thick sweatshirt because her body’s metabolism had slowed so much that she was not producing adequate heat – was bawling.

A major source of my frustration was writing chart notes. The documenting itself, which at this time was still typically done by hand, was not the issue. Rather, the problem was that each of my preceptors wrote notes differently, yet each of them felt strongly that their way was the singular right way. Each time my clinical preceptor changed, they would initially be disgusted by my notes, and by the time I adjusted and was documenting to their liking, it would be time to switch preceptors and the cycle repeated. For example, one of my preceptors co-signed one of my notes and told me “very good.” My next preceptor looked at that same exact note and told me she would not have agreed to sign it. Then I modeled my notes after her own, but my next preceptor looked at them and tore them apart, including calling them grammatically incorrect, which they certainly were not. Sometimes they allowed me to cross out and initialize the words or passages they wanted rephrased, but they were not always so generous. One time, I remember having to stay late to copy over an entire page-long note because my preceptor took issue with literally one word. “Different” is not synonymous with “wrong,” but try telling that to these people.

Furthermore, now that I am a practicing dietitian, it turns out that how I write my notes does not matter. Nobody cares. The insurance companies who occasionally request my notes as part of their decision-making process for determining coverage do not care, and the doctors – who rarely read the notes that I send them – definitely do not care.

Criticizing our note-writing skills was just one of their ways of giving us a hard time and treating us as less than. The BIDMC clinical units had a class system with doctors at the top of the hierarchy, RDs somewhere behind nurses (hence the derogatory nickname for dietitians, “Jello ladies”) and dietetic interns even lower. Having a power structure makes sense in some contexts – if a patient codes, knowing who is in charge and what each person’s responsibilities are streamlines care and saves precious time – but other times it is counterproductive. Pushing people down is a lost opportunity to gain their insight, which in a healthcare setting means worse patient care. One of my fellow interns described our experience as being similar to pledging a sorority, and just like with pledges joining Greek life or rookies on a sports team, hazing and treating the new folks with disrespect has never made any sense to me.

Around the time of my rotation at Children’s, I realized how depressed I had become since starting the internship, particularly its clinical portion. My morning commute consisted of taking the 51 bus from my West Roxbury apartment to Reservoir, then taking the green line to the Longwood Medical Area, and it got to the point where I legitimately hoped my bus crashed so I did not have to go to work. Rationally, I knew that of course the internship would eventually finish, but my heart felt differently, as I could not see myself making it through to the end. It was at this point that I knew I needed therapy.

Outpatient Counseling

After my clinical rotations were over, things began looking up. A new calendar year began and suddenly the internship’s June end date felt attainable. Around this time, I also met Joanne. (People assume we met through dietetics, but that is not the case; it was just coincidence that we were both in the same field.) Also of significance, this is when my outpatient counseling rotations – which were my favorite rotations of the entire internship – began. For the first time in a long while, I could see the light at the end of the tunnel.

In my medical nutrition therapy rotation, I worked closely with BIDMC’s outpatient dietitian, who counseled patients with cardiovascular disease, diabetes, liver disease, and other ailments. One of the aspects of this rotation that I most appreciated was that I had a chance to observe her before I began to counsel patients myself. Given that I only had one counseling course in nutrition school, I valued the chance to learn more, especially from someone as seasoned as she was. It was from her that I learned that a dietitian can be simultaneously informal and professional, that keeping the vibe of an appointment relaxed can help patients feel more at ease.

When we were not in the clinic, we went out into the community on a roving healthcare van that stopped in some of the more impoverished areas of the city. We gave out condoms, took blood pressure readings and blood sugar checks, and answered nutrition questions for anybody who stopped by, all for free. The only specific nutrition discussion I can remember having with someone pertained to the sodium content of her favorite spice mix. During our breaks, my preceptor took me around the neighborhoods to visit restaurants, food pantries, and grocery stores. We talked with some of the regulars who relied on the pantries, and I was struck by the realization that food insecurity is not some abstract notion in textbooks or a relic of a bygone era, but rather a present challenge for many people in our own city.

One of my other outpatient rotations was with a BIDMC dietitian who specialized in Celiac disease and food allergies. As part of this rotation, I – along with one of my fellow interns – wrote the elimination diet manual that BIDMC went on to use, although I imagine they have long since replaced it with an updated version.

The bariatric clinic had two outpatient dietitians that I shadowed for a week, but I remember little of what went on there. They arranged for me to observe a lap band fill, and I also remember watching a Roux-en-Y bypass surgery being broadcast live to a monitor outside the operating room. One specific memory I have is of waking up and realizing I had just fallen asleep while sitting in on a counseling session. Both the dietitian and patient noticed. I was super embarrassed, but they were kind about it. After the appointment, the dietitian gently told me that I needed to figure out how to get more sleep. An aspect of the internship that I had not anticipated was just how much work we would have to do after hours. Typically, I woke up early, spent the day at the hospital – or wherever my particular rotation was – went to the gym, then stayed up very late reading, researching, or doing whatever other tasks I had to handle. The hours were certainly nothing like the legendary marathon shifts that medical residents work, but they were exhausting nonetheless and took a cumulative toll.

For another week, I got to spend time shadowing dietitians at the Joslin Diabetes Center. This was a fantastic experience. The nurses, doctors, exercise physiologists, and dietitians treated each other with a level of mutual respect that was absent at BIDMC. The staff did an excellent job of putting themselves in the patients’ shoes and empathizing with how scared and confused some of them were. Counselors often spent extra time with them and told them to call or email anytime with additional questions. This is how outpatient counseling is meant to be, I thought, and I have done my best to follow their example.

Research

Given my experience and interest in research, I was looking forward to my rotation in BIDMC’s general research center. We implemented the eating protocols for whatever nutrition-related studies happened to be taking place there at the time. One morning, they let me try the metabolic hood, an indirect calorimetry device that covers the subject’s head like a motorcycle helmet and uses their oxygen intake and carbon dioxide output to estimate their resting metabolic rate.

A few months after the internship was over, I applied for and subsequently accepted a research position at another general research center in Boston. Before starting the job though, I came to realize that while I do like research, it is not my passion, and my heart was really in counseling. I felt awful rescinding my acceptance, as I knew I was putting the research center in a tough spot and harming my own reputation, but it was the right call.

Plan-Your-Own Rotations

For two weeks, we were left to plan our own rotations in subject areas where we wanted additional experience. Having performed statistical analyses for a professor in the Tufts University nutrition school when I was an undergraduate at the university, I reached out to her to see if I could do any similar work for her as one of my plan-your-own rotations. Looking back at my files from the rotation, I see a bunch of charts and graphs that I put together for her, but I have no idea what the subject matter was.

Given my background as a personal trainer, I wondered if I might have a future working at a health club doing both training and nutrition counseling, so I sought out a dietitian who had that exact job and shadowed her as my other plan-your-own rotation. Two specific memories stand out to me. The first was when she offered to counsel me, just as she would one of her clients, so I could get a sense of how she practiced, and she food shamed me for eating dessert. The experience made me realize how harmful judgment is and how fear of it can understandably inspire patients to misrepresent their eating as a defense, as I was certainly tempted to lie to her going forward after seeing how she reacted to my reported dessert. The second stand-out memory is of an argument she had with a woman in one of her group fitness classes. The woman insisted that she was following the meal plan that the dietitian had given her, while the dietitian insisted that she was lying because if she was truly following the meal plan, she would be losing weight, which she was not. The argument was uncomfortable to witness, and I felt badly for the woman. When I later learned about Health at Every Size, I remembered this argument as an example of the trouble that can arise when we think we have more control over body weight than we actually do.

Community Nutrition

One of my community nutrition rotations was with ABCD Head Start. Unfortunately, I have absolutely no recollection of this experience other than seeing one of the workers get reprimanded for bringing Reese’s peanut butter cups into the nut-free facility.

The other rotation was with Boston Public Schools. My main tasks were to create educational materials, such as bulletin board materials and newsletters, for students and their families. The administrative office was a very casual environment, and I remember my preceptor and her colleagues giving me advice regarding how to approach Valentine’s Day with Joanne, as they felt I had to walk a fine line between not being dismissive of the holiday yet not coming on too strong given that we had only been dating for about a month at that point. Like a true intern, I was sent to get coffee for my preceptor, who once playfully slapped me for writing material for a bulletin board by hand instead of printing it out.

Class Days

We spent Tuesdays through Fridays at our rotations, but Mondays were our class days. The eight of us BIDMC interns would get together – sometimes by ourselves, and sometimes with other interns from the area – to spend the day learning about a given subject. We spent one day learning about mindful eating (which, by the way, is not synonymous with intuitive eating, although I suppose that is a topic for a different blog) and another about pediatrics. A dietitian from Gatorade came to talk with us about sports nutrition. One of the hospital’s gastroenterologists taught us about, well, gastroenterology. We spent a day at the Army’s research facility in Natick learning about field rations. The other class day topics escape me, but there were certainly more.

Along the way, each of us had to give presentations of our own to the class. Inspired by my visits to Native American reservations during my cross-country bicycle ride, one of my research projects looked at the dietary patterns of the residents of these reservations. Another one of my research projects looked at how other populations around the world treat constipation, which is how I learned about Pajala porridge and that people in the southern hemisphere use kiwifruit the same way that we use prunes. Looking at my notes, I see that I had started research for a presentation on competitive eaters and how they are able to hold so much food in their bodies at once, but apparently I abandoned the topic for some reason. One of the other interns and I gave a joint presentation on VACTERL association, which I had to Google just now to remember what it is.

In the end . . .

This has been a difficult blog to write. Generally speaking, these are not happy memories. The stress, the exhaustion, and the frequent disrespect made for a difficult year in which I did not learn as much about nutrition as I expected.

Additionally, I was angry – mad at the internship for not being what I wanted it to be, and mad at myself for putting myself in this situation. During the application process, internship directors were telling me that due to my strong resume and being a minority in a female-dominated field, I could go to any internship that I wanted, that it was up to me to decide where I wanted to be. Because of the geographic constraints I put on myself and by process of elimination, I ended up at BIDMC, which was supposedly one of the most prestigious programs in the country, but in hindsight, it was not the right one for me.

At the same time, I hesitate to go so far as to say I regret having gone there. Changing any element of the past would result in a different present than the one I have now. As I stated both before and during the internship, I wanted to be an outpatient counselor, and now that is what I do. While I might not have enjoyed my time at BIDMC, it is part of the route that got me here.